A CASE OF B/L PEDAL EDEMA, ALTERED SENSORIUM AND DYSPNEA.


CHIEF COMPLAINTS:


📌Dyspnea on exertion since 5 days and dyspnea on rest since 2 days

📌Yellowish discoloration of eyes since 5 days

📌Vomiting since 5 days .

📌B/L pedal edema since 3 days.

📌Fever since 2 days .

📌Decreased urine output since 2 days.

📌Unable to pass stools since 2 days and hematuria since 2days.

📌 He had 10-12 episodes of vomitings with food as content non-bilious since  4 days.

📌 Non blood tinged and  developed bilateral pedal edema up to knees.

📌 He received  Inj Ceftriaxone, IV fluids, Syrup Hepamerz in the outside hospital.

📌  He later started experiencing high grade, continuous fever since the last 2 days along with decreased urine output.

📌 unable to pass stools.

📌 Because of financial issues they got discharged from that hospital and presented to our casualty at 7PM on 25/7/21

📌Altered sensorium since 1 hour before coming to hospital.

🌡 TREATMENT HISTORY :
   
     No significant  history 


🌡️PERSONAL HISTORY : 

-  Married 

- Occupation : Driver

- Apettite loss:No

- Bowels : irregular

- Micturition : Decresed

- No H/O known drug allergies

-Alcohol : regular (7 years)

-Tobacco -Yes


🌡PHYSICAL EXAMINATION : 

A) GENERAL EXAMINATION :

 - Pallor- NO 

- lcterus-YES

- Cyanosis-No.  

- Clubbing of fingers/toes- No

- Lymphadenopathy-No

-Oedema of  feet- YES(B/L PEDAL EDEMA)

-Pupils-B/L pupils dilated

- Malnutrition - No

Dehydration -NO 

- No H/O pallor, cyanosis , lymphadenopathy , clubbing of fingers or toes , dehydration

- Temperature : Afebrile 

- BP : 70\50 mmHg 

- PR : 49 BPM

- SPO2 : 85% at room air 

-GRBS:135 m/dl

-RR-36 cpm


🌡SYSTEMIC EXAMINATION:

B) CVS 

- Thrills : No 

- Cardiac sounds - S1 , S2 heard 

- Cardiac murmurs : No 

C) RS 

- Dyspnea : YES

- Wheeze : No 

-Inspiratory crepts-B/L IAA

D) ABDOMEN 

- Bowel sounds : YES 

E) CNS 

- altered sensorium

★ REFLEXES 

-Absent 


INVESTIGATIONS:

ECG:


X-RAY:





🌡SEROLOGICAL INVESTIGATIONS: ON 25/07/21(OUTSIDE)

Hb-13.8

TLC-14,100

PLT(plateletcount)-51,000

Serum creatinine: 3.7 mg/ dl

Blood urea: 128 mg/ dl

Sodium : 133 mEq/L

potassium : 3.6 mEq/L

chloride : 53 mEq/L

Liver Function Test:

TB   -19

DB   -7.8

IB-11.2

AST -147

ALT  -185

Alkaline Phosphate-135

TP:6.9

Alb-3.7

A/G-1.1 

Electrolytes:

Na-155 mmol/lit

K-5.4 mmol/lit

Cl-95 mmol/lit

Blood Glucose Test-Positive

S.lyase -102

PT-29 sec

INR-2.8

APTT-50 sec


Dengue-NEGATIVE 

HIV-NEGATIVE 

HCV-NEGATIVE 

HBS Ag-NEGATIVE 

ON 25/7/21(In Hospital)


Hb-13.9

TLC-16,950

PLT(plateletcount)-63,000

Serum creatinine: 2.7 mg/ dl

Blood urea: 89mg/ dl

Sodium : 133 mEq/L

potassium : 3.6 mEq/L

chloride : 53 mEq/L

Liver Function Test:

TB   -12.1

DB   -2.2

IB-11.2

Utica acid:6.2

AST -680

ALT  -140

Alkaline Phosphate-135

TP:5.2

Electrolytes:

Na-120 mmol/lit

K-5.1 mmol/lit

Cl-80 mmol/lit

ABG

pH:7.06

pCO2:18.4 mmHg 

pO2-not mentioned 

HCO3-7.9 mEq/mol




S.lyase -43

S.Amylase-82

BT:2 min 30 seconds 

CT:5 mins


PT-28sec

INR-2.0

APTT-57 sec


26/7/21:
  Over night BP monitoring chart:


ABG Report:
At 3AM:





Hemogram:



29/7/21

ABG Report:


Liver Function Test:







PROVISIONAL DIAGNOSIS:

Hepatic encephalopathy with acute decompensated liver failure
Hypotension secondary to ? Sepsis 
Right heart failure

Treatment:25/7/21
  1. IVF-30 NS 
  2. Inj.THIAMINE 1 amp in 100 ml IV/ID
  3. Inj. VIT K IV/in 100 ml NS -DD
  4. Plan for FFP transfusions 
  5. TAB.Udiliv 300 mg po/TID
  6. Syp . Lactulose 15 ml /po/TID
  7. Syp.  Hepamerz 10 ml/po/BD
  8. Inj. PIPTAZ  4.5 gm/IV—2.25 gm/IV/TID
  9. Inj.methyl prednisole 40mg/IV/OD in 100ml NS
  10. Propped up posture/head end elevation
  11. TAB.RIFAGUT 500 mg BD/RT
  12. Inj. PAN 40mg IV/OD
  13. Oxygen supplementation maintains sPO2>95%
  14. Monitor vitals-BP hourly 
  15. Strict I/O charting
  16. Inj. Noradrenaline 12ml/hour infusion
  17. GRRS charting 6th hourly
  18. Inj.Vasopressin infusion 2.4 ml/hour
  19. Inj.LASIX 20mg IV/BD 8 AM - 4PM  IF SBP >110 mmHg
  20. ABG every 6th hourly.

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