Medical case report_ravi_chang_final


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Medical case report_ravi_chang_final

  1. 1. MEDICAL CASE REPORT I.PATIENT’S ID. 1. 2. 3. 4. Name:- Zaviyalev Oleg Vyachislavovich Age:- 38 years (5th May 1968) Occupation:- Guard Home address: Street Chetaeva, House – 62, flat number 63, Kazan 5. Date of Admission:- 4th May 2006 II.MEDICAL HISTORY 1. CC: • Epigastric Pain: severe burning pain in left hypochondrium. Pain has engirdling character, is more pronounced in supine position than in sitting position. This pain becomes more intense 30-40 min. after the meal. This last for about 30 – 40 min. After fasting patient get relief from the pain so to get relief from the pain the patient avoid having his meal regularly. • Edema of lower extremities: - in lower extremities mainly in the foot and the shank region. The edema is continuous and increases during normal physical exercise. After normal physical exercise there is pain n both legs and patient gets some relief from this pain during rest. • Inversion of sleep: - patient also complaints about bad sleep. Patient can’t sleep in night, but he completes his sleep during the day, sleep span is about 3- 4 hours. • Stool complaints:- patient goes to toilet for defecation 7-8 times/ day with only a feeling of defecation, without stool. Stool has a normal color with a very low quantity.
  2. 2. • Weakness –it is also one of the complaint patients the height of weakness is in the morning. In morning patient feels himself week but as the day proceeds he starts feeling better. He lost his weight about 7-8 kg during his span of disease. Secondary complaints o Cough – patient has a irregular cough with green colored sputum, quantity is about 20-30ml/day o Dyspnea – appears mainly after normal physical activity. Exhalation dyspnea o Urination – patient goes to the toilet for urination after every 30 min.and complaints about the abdominal pain during urination. 2. HPI: From last 20 years patient used to drink alcohol 3 times a week. He is alcohol abused from last 20 yrs. Every time he used to drink for about 1 litre Vodka or spirit. In the month of March 2006 he drunk everyday 1litre spirit, and after that he started feeling weakness & pain in the lower extremities and epigastric pain. The patient also lost his weight by 7 kg in a month. Patient had closed trauma of head in the year 2001, after that the problems regarding to sleep (inversion of sleep) occurs. At the time of admission patient had pain in epigastric region, weakness, edema of lower extremities. Patient was referred to the hospital by his district physician. 3. PMH: • In 1973 when the patient was 5 years old he caught cold n was diagnosed was established as Bronchitis • Hypotension was diagnosed in 1992 with blood pressure of 90/60.
  3. 3. • The patient has closed trauma of his head in 2001. From that incidence he got the problems of inversion of sleep and bad memory. • Fracture of his middle phalange of his little finger in 2001. • He doesn’t have any venereal disease. • He has done all required immunizations. 4. FH: Father died at the age of 27 yr old but he doesn’t know exact reason of his death. Mother is 57 yrs old and don’t have any problem. He also have 1 brother who is 34 yr old healthy. Patient doesn’t know exact data about grandparent. 5. PSH: Born in kazan on 5th may 1968, from 1st pregnancy. At the time of birth father was 23yr old and mother was 19yr. Breast feeded began walking at the age of 2yr, speaking at 3yr, gone to school at the age of 7yr he completed 10th class at the age of and did not studied further. Emotional atmosphere at home is stressful. He lives in 2 room apartment, separate, comfortable with partial facilities on first floor with his family (2 members) with mother and brother. Clothes and footwear are hygienic and corresponding to season. He work as guard, he works for 12hr from 8 a.m. to 8 p.m. His feeding is full, regular and prefers non-veg dishes as sausages, soup and meat. He used to play football when he was child. He spends his free time in watching football or Hockey. He is Christian by religion. His pubertal period had gone without any complications at 14 year. He had sexual contacts from 21 year. He is a bachelor.
  4. 4. 6. MH: • Tobacco smoking; started smoking at the age of 16yrs, smokes 1 packet, about 20cig/day. He is smoking from last 22yrs. • Alcohol consumption: started drinking at the age 18yrs.He use to drink alcohol from last 20yrs. He drinks 3-4 times a week, near about 750ml vodka or spirit. • Don’t take any narcotics and illicit drugs. III. PHYSICAL EXAMINATION FINDINGS: General condition:- satisfactory, temp: - 36.6 C. Patient’s position:- active, level of consciousness: - clear. Face expression:- Painful expression no cyanosis of lips, cheeks, nose and ear. Constitutional type:- normosthenic. Height: - 168 cm, weight 54 Kg, BMI 19.36 kg/m2 No Gait and Bearing abnormalities. Color of skin is physiologic, skin is moist and elastic and state of hair is masculine. No exanthema, hemorrhages, vascular changes, scars. No digital clubbing of nails. Thickness of cutaneous fold below scapula is 1.5 cm, edema of lower extremities (foot & shank region). Thyroid gland: - Is palpable & diameter of isthmus is about 1cm. Lymph nodes are not palpable. Muscle general development of satisfactory and there is no tenderness on palpation. His muscle tone is regular and muscular strength is normal. Bones ;( examination of chest, spine, extremities & skull) Deformity of nasal bone due to trauma in yr 2001.
  5. 5. Joints; On examination of joints changes in joint configuration, swelling or crepitation (crunching) during motion are not reveled. Respiratory System: Nasal breathing is not laboured. Chest shape: - Flat, constitutional type: - Normosthenic. Respiratory pattern is abdominal, respiration s regular with respiration rate 20/min.Chest respiration motion of both sides of chest are even, symmetric and there is no lag in motion, additional respiratory muscle doesn’t participate in respiration. There is no area of tenderness on thoracic on cage, thoracic cage is elastic. Tactile fremitus is equal on both sides of chest on upper and lower part of back. Percussion Data: On comparative percussion, resonant note is heard over the all fields above lungs. On topographic percussion, height of apices pulmones standing from the front: on the right-3.5 cm above clavicle, on the left-3.5 cm above clavicles; from the rear: on the level of 6 vertebra. Krenig’s areas width: on the right-7 cm, on the left-7 cm. Lower lung borders: Topographic lines Parasternal Midclavicular Right VI rib VI intercostal Left - space Anterior axillary VII intercostal space Midaxillary VII intercostal space VIII intercostal VIII
  6. 6. space intercostal space Posterior axillary IX intercostal space IX intercostal space Scapular X intercostal space Spinous process XI thoracic vertebra Para vertebral X intercostal space of Spinous process XI thoracic vertebra of Defining of diaphragmatic excursion: Topographic lines Right Inspiratio n Midclavicula r Midaxillary Scapular 3 2 Left Expiration Sum Inspiratio n 3 2 6 4 3 2 Expiration Sum - - 3 2 6 4 Auscultation Data: Main breath sound is harsh breath sound over the lung. No any adventitious breath sound. On bronchophony no changes in sound transmission on both sides. Cardiovascular system:
  7. 7. No deformities in precordium region. Apical impulse:- apical impulse and present at 5th intercosal space 1cm medially from left midclavacular line, area of apical impulse is about 1.5cm, strength is strong. Cardiac impulse:-no Epigastric pulsation:- no Other pulsation:-no Any kind of thrills are not present. Percussion Data: Cardiac relative dullness borders: Right: - right border is situated 1cm laterally from right sternal edge IV intercostal space Left: - left border is situated 1cm medially from left midclavicular line in V intercostals space Upper: - upper border is situated 1cm lateral from left sternal line at the level of III rib. Heart diameter:- 3+9=12cm Heart configuration is normal. Cardiac superficial dullness border:Right:-right border is situated at left sternal edge in V internal space. Left:-left border is situated 2.5cm medially from left midclavacular line. Upper:-IV rib level. Superficial dullness diameter: - 6cm Vascular bundle width: - 5cm Auscultation Data: S1 and S2 are regular and normal. At the base of heart S2 is louder than S1 Any kind of murmurs are not present. Heart rate:-78/min is regular. Vessels examination;Arterial pulse is 74/min and regular. Filling is satisfactory; strain is hard and equal on both arms. Arterial palpation and auscultation;Femoral artery is palpable and superficially located, pulsation is strong and filling is satisfactory. Popliteal artery deep located, pulsation is weak filling is satisfactory. Posterior tibial artery is not palpable.
  8. 8. BP on left arm 110/70 mmHg BP on right arms 110/65 mmHg Venous pulse:-venous pulse is negative, central venous pressure is 3cm. Gastrointestinal tract: -Tongue is white coated and with rough appearance. -Mucous membrane is icteric, especially hard palate and bottom surface of tongue. -Tonsils are not inflammated. -There is bleeding from gums during teeth cleaning. -No any carious tooth is present. Abdomen shape: flat, even. Regular respiratory motions of abdominal wall. On percussion, tympanitic note is heard over the abdomen. On superficial palpation there is tenderness in the Guberegritz – Skoolsky zone and patient feel pain during palpation in this area. No hernia, tumors, no dehiscence of abdominal muscles. Shchetkin-Blumberg’s sign is negative. Sigmoid colon is located in left iliac region, palpable, 3 cm in diameter, cylindrical in shape, and smooth, elastic consistency, painless. Cecum is located in right iliac region, palpable, 1.5 cm in diameter cylindrical in shape, and smooth, elastic consistency, painless. Transverse colon, ascending colon, descending colon are not palpable. Using percussion, auscultopercussio, auscultoaffriction, splashing sound methods, the lower stomach border is defined at the level 3 cm above the umbilicus. Pancreas is not palpable but during palpation there is pain in the Guberegritz – Skoolsky zone. Transverse colon is not palpable. Ascending and descending colon are not palpable. Liver span after Kurlov Along Midclavicular line – 15 cm Midsternal line – 9 cm Along left costal arch – 6 cm
  9. 9. Liver palpation:-palpable 4cm below costal arch. Lower border is smooth and with tender edge. Spleen area: along horizontal axis- 8cm Along vertical axis- 6cm Urinary system : Kidneys, urinary bladder are not palpable. Pastenatsky’s sign is negative. IV. PROVISIONAL DIAGNOSIS:Main  Alcoholic liver disease chronic hepatitis: parenchymatous jaundice with cholestatic component;  Hepatocellular insufficiency: Hepatic encephalopathy of combined origin (traumatic + alcoholic), prodromal stage;  Chronic pancreatitis, recurrent form, moderate course, exacerbation period. Accompanied  Chronic bronchitis, remission stage. V. INVESTIGATION DATA a) Blood analysis:Leukocytes - 4.5 ×109 /l, neutrophils asegmented- 5%, segmented – 62%, lymphocytes - 27%, monocytes - 4%, eosinophils -2%. b) Biochemical blood analysis:-
  10. 10. Total bilirubin- 44/8/36 m mol, ALT-55.36 m mol/lit, AST35.6 m mol/lit Amylase-17.1 gm/lit, Urea- 4.9 m mol/lit, creatinine- 69.0 m mol/lit, Cholesterol-5.9 m mol/lit. Total Protein- 55.19 gm/lit. c) Urine analysis:Leukocytes – 4-5, Bilirubinurea- + ve, Urobilinogen- -ve, Total bilirubin- 200 m mol/lit, direct100 m mol/lit, indirect- 100 m mol/lit d) Ultrasound:Liver; right lobe- 154 mm (with signs of stephoasis component), Gallbladder; 40/30, duct- 5 mm, Pancreas; head35 mm body- 21 mm VI. CLINICAL DIAGNOSIS:Main  Alcoholic liver disease chronic hepatitis: parenchymatous jaundice with cholestatic component;  Hepatocellular insufficiency: Hepatic encephalopathy of combined origin (traumatic + alcoholic), prodromal stage;  Chronic pancreatitis, recurrent form, moderate course, exacerbation period. VII. PATHOGENESIS OF SYMPTOMS & SIGNS • Severe abdominal pain:-
  11. 11. Severe abdominal pain which is derived from dilation of duct system causing ductal and parenchymal hypertension, or from inflammation of parenchyma causing pancreatic ischemia. Patient have recurrent attacks of pain, elevation of serum amylase, failure to secrete pancreatic and malabsorption of fat and fat soluble vitamins, which results in weight loss. Due to inflammation of pancreas the size of head of pancreas is increase, which results in activation of pain receptors. These pain receptors give sensation of pain in epigastric region. Because of the inflammation process pain gets engirdling character. This pain is steady, boring and persist without relief for many hours and usually for several days. • Edema of lower extremities:The movement of protein (eg. Albumin, clotting factors, lipoproteins) between hepatocytes is markedly impaired so Hypoproteinemia develops. Plasma protein level is decrease & because of Hypoproteinemia osmotic pressure gradually decreases & balance between oncotic pressure gradually decreases and due to high portal venous pressure fluid accumulates into intracellular spaces. The reduction in plasma protein concentration results from destruction of the liver cells thus reduced the ability of the liver to synthesize enough protein. is also associated with large amount of fibrous tissue in liver structure , which greatly impedes the flow of portal blood through the liver this in turn rises capillary pressure through the portal vascular bed which also contributes the leakage of fluid and proteins into lower extremities and oedema develops. • Hepatocellular insufficiency:Two physiological factors appear to be important in the genesis of this disorder- 1) severe loss of hepatocellular function 2) shunting of blood around the chronically diseased liver due to these two factors. Liver metabolizes and detoxifies digestive products brought from the intestine by portal vein. In liver disease these products escape into systemic circulation, if portal blood bypasses parenchymal cells or if the function of these cells impaired, the resulting toxic effects may produce the symptoms of hepatic
  12. 12. encephalopathy. The another most important function of the liver mainly protein metabolism is altered formation of the urea by the liver removes ammonia from the body fluids. Large amounts of ammonia is formed by the deamination process and additional amounts are continually formed in the gut by bacteria and then absorbed into blood therefore if the liver does not form urea the plasma concentration of ammonia can rise rapidly and results in hepatic coma. Patient exhibit a spectrum of disturbances in consciousness ranging from behavioural abnormalities to marked confusions. Hepatic encephalopathy is regarded as metabolic disorder of CNS and neuromuscular system. In this case The disorder of CNS may due to trauma of head or due to alcohol. In most instances there are only minor morphological changes in the brain due to which normal sleep cycle is disturbed. Patient cant sleep during night and sleeps during the day time. It is due to neuropsychiatric syndrome caused by liver disease and usually associated with portal systemic shunting of venous blood. But the exact pathology behind the inversion of sleep is unknown. • Hepatomegaly:During percussion we can find the enlarged liver, and on palpation the lower liver edge can be palpated 4cm below costal arch. The lower liver borders are depressed. On ultrasound we can found liver enlargement. Liver enlargement is an initial change and is most common response to alcohol ingestion. The increased liver fat is derived from the diet, and from free fatty acid mobilized from adipose tissue. The lipid synthesized in liver is inadequately degraded and excreted. Fat droplets of various sizes are found in most of the hepatocytes. Other features include hydropic change in early stages of alcoholic liver injury and giant spherical mitochondria. The former swollen, balloon like hepatocytes reslts from impaired release of proteins and lipoproteins. These cells degenerate and disintegrate. So the liver size is increase (hepatomegaly). • Biochemical blood analysis:-
  13. 13. Total bilirubin- 44/8/36 m mol, ALT-55.36 m mol/lit, AST-35.6 m mol/lit Amylase-17.1 gm/lit, Urea- 4.9 m mol/lit, creatinine- 69.0 m mol/lit, Cholesterol- 5.9 m mol/lit. Total Protein- 55.19 gm/lit. In biochemical blood analysis the conjugated bilirubin(44/8/36 m mol) level is increased, it is caused either by obstruction of bile ducts of bile ducts or by damage to hepatic cells. The rate of bilirubin formation is normal, but formed bilirubin can not pass from blood to intestines. While the free bilirubin still enters the liver cells and becomes conjugated in usual way. This conjugated bilirubin is then return to blood. Thus most of bilirubin in plasma becomes conjugated type rather than free type. So conjugated hyperbilirubinemia can be seen in blood analysis. In blood analysis we also can see the decrease level of total protein (55.19gm/lit) (hypoproteinemia). It is caused due to the impaired movement of protein (eg. Albumin, clotting factors, lipoproteins) between hepatocytes. The movement of these proteins markedly impaired between hepatocytes so Hypoproteinemia develops. We also can see the sharp increase in serum amylase (17.1 gm/lit) and ALT (55.36 m mol/lit). • Urinalysis:Leukocytes – 4-5, Bilirubinurea- + ve, Urobilinogen- -ve, Total bilirubin- 200 m mol/lit, direct100 m mol/lit, indirect- 100 m mol/lit In urinalysis increase in both conjugated (100 m mol/lit) and in unconjugated (100 m mol/lit) biliruin level. We can also see the urobilinogen is negative in urine. It is caused by the intrahepatic obstruction of bile flow, so o bilirubin can not reach to intestine to be converted into urobilinogen by bacteria. Therefore no urobilinogen is reabsorbed into blood and none can be excreted by kidney into urine. So the urobilinogen in urine is completely negative. VIII. SUBSTINTIATION OF DIAGNOSIS:-
  14. 14. Diagnosis is based on: • Complaints of patient: Shows pain in epigastric region, burning pain. This pain has engirdling character. Patient also complaint about edema and pain in lower extremities. Weakness is also a complaint of patient, height of weakness is in morning. Patient can’t sleep in night but he completes his sleep during daytime (inversion of sleep). Patient looses his weight by 7kg in a month. • Past medical history & History of alcohol consumption:Patient had closed trauma of head in yr 2001, after that complaints like inversion of sleep and bad memory had been started. Patient is alcohol abused from last 20 years, every time he drinks about 1 litre vodka or spirit. • Physical finding: Tongue is white coated with rough and mucous membrane has icteric appearance. Shows hepatomegaly (liver enlargement), lower liver border is depressed and lower liver edge has smooth, rubber elastic consistency, and is palpable 4cm below costal arch. During abdominal palpation there is tenderness in Guberegritz – Skoolsky zone, tenderness in this zone is characterized for pancreatic body inflammation. • Investigation data: Ultrasound shows enlargement of liver with steatosis (hepatomegaly), signs of enlargement of pancreatic head and constriction of gallbladder. In biochemical blood analysis direct bilirubin is increased (conjugated hyperbilirubinemia) and there is sharp increase in ALT (55.36 m mol/lit) and serum amylase (17.1 gm/lit). Biochemical blood analysis also indicates hypoproteinemia (55.19 gm/lit). Urinalysis indicates increase in both conjugated (100 m mol/lit) and unconjugated bilirubin (100 m mol/lit) level, Urobilinogen in urine is negative.