LONG CASE 1801006116

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem collective current best evident based input.

40 year old male laborer by occupation resident of nalgonda came to opd with

CHIEF COMPLAINTS:

Abdominal distension since 3 months

B/L pedal edema since 1 week

yellowish discolouration of eyes since 1 week 

.Shortness of breath since 1 week

.Fever since 1-2days

HISTORY OF PRESENTING ILLNESS:

Patient was apprently alright 3months ago after which 

         

• associated with abdominal distension Insidious in onset ,gradually progressed to current state distension, changes with position,diffuse in nature

    he developed yellowish discolouration of eyes  since 1 week Insidious onset,gradually   progressive , associated with h/o high discolouration of urine and itching 

• c/o B/L pedal edema since 1week ,insidious onset ,gradually progressed till ,not associated with chest pain,or palpitations

• C/o Fever since 1-2days,High grade not associated with diurnal variation ,no aggregating and relieving factors

No h/o ,pale coloured stools,loss of weight,loose stools,vomitings

No h/o ,decreased urine output,facial puffiness, ,frothy urine

No h/o abdominal pain,obstipation or vomiting 

 

PAST HISTORY:

No H/o HTN,DM,TB,ASTHMA,Epilepsy

No history of blood transfusions or chronic drug intake 

FAMIKY HISTORY:

no similar complaints in the family,

PERSONAL HISTORY  :

• Alcoholic since 5 years drinks about 180ml of alcohol per day

• Drinks Toddy occasionally 

• Non smoker

• Bowel bladder habits regular

• Mixed diet

• Sleep inadequate

GENERAL EXAMINATION:

Patient consent is taken, examined in a well lit room Exposed from nipple to mid thigh 

Conscious,Coherent,cooperative well oriented with time place and person 

PR:74bpm ,regular rhythm normal character and volume 

Bp:100/60mmhg 

Temp:103F measured orally

Spo2 :96% at Room air

RR:28cpm

Pallor+, present

icterus + present 

no clubbing,no lymphadenopathy,no cyanosis 

Pedal edema+ upto knees,pitting type

Head to toe examination 

Hair is sparse 

Palmar  erthema present 

3 spider nevi are present 

 

SYSTEMIC EXAMINATION:

• Ora cavity normal

• No ulcers or patches on patches on palate or mucosa

• 
  

Per abdominal examination:

Patient exposed from nipple to mid thigh and examined in supine position

INSPECTION: 

• Shape:Distended flanks full

• Umbilicus:inverted,vertically drawn down

• Skin over the abdomen is shiny

• No visible peristalsis, 

• Visible superficial abdominal vein running vertically down is seen

• External genitalia normal

Palpation:

On superficial Palpation

• All inspectory findings are confirmed

• Tenderness+

• ,diffuse all quadrants

• No Rebound tenderness

• No guarding,rigidity

Ondeep Palpation 

palpable masses appreciated

Margins of liver appreciated

Percussion

Upper border of liver dullnessis Percussion at right 5th intercoastal space along the mid clavicular lineon full expiration

Shifting dullness +

fluid thrill+

Puddles sign not elicited

Liver span-12cm

Percussion of spleen : dullness in 9th inter coastal space of anterior axillary line

Auscultation 

Bowel sounds+

No arterial bruit,

RESPIRATORY SYSTEM

Inspection 

• Shape of chest:Bilaterally symmetrical,Elliptical in shape

• No visible chest deformities

• Abdomino thoracic respiration,No irregular respiration

• No tracheal shift

• No dropping of shoulders, on both sides,no sinuses,scars,engorged veins

Palpation:inspectory findings confirmed by Palpation 

• Chest movements -normal

• TVF-decreased in right infra mammary area

Percussion:

Resonant note heard over all areas except right infra mammary area

Auscultation:

Norma vesicular breath sounds

, breath sounds normal

Vocal resonance:Decreased in basal areas

Cardiovascular system:

Inspection:precordium normal,apex beat :5th ICS half inch medial to mid clavicular line

Palpation:inspectory findings confirmed,No thrills or parasternal heave

Auscultation: S1S2+,no murmurs

CNS:

HMF normal, Awake and oriented

flapping tremors present

cranial nerves intact,motor and sensory examination normal

No cerebellar or meningeal signs

PROVISIONAL DIAGNOSIS:

Decompensated cirrhosis of liver with Ascites

INVESTIGATIONS:

Hemogram 

RFT

Serology

Complete urine examination

Renal function test

Urea: 26

Creatinine:0.8

Sodium: 128

Potassium:3.0

Chloride:96

Hemogram:

Hb :6.8

Tlc:130000cells/ccmm

Neutrophils:86/

Platelets:1lk

PBS:

Microscopic hypochromic

LIVER FUNCTION TEST:

total bilirubin:8.76mg/dl

AST:161

ALT:72

Albumin:1.51

Serology:

PT 45 sec

Amylase:42

ASCITIC FLUID

cell count 1570cells

Sugar:46

Protein:0.7

Albumin:0.21

SAAG:1.35

• Inj Cefotaxim 1gm IV Bd

• Syp lactulose to pass 3-4stools /day

• 4FFP s and 1 PRBC transfusion was done during his hospital stay

• Tab LASIX 20mg BD

• Fluid and salt restriction

Final diagnosis:

DECOMPENSATED liver disease with ASCITES