1801006168 long case 

March 20 2023 

This is an a online e log book to discuss our patient's 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 with collective current best evident based input.

This E blog also reflects my patient centred online learning portfolio and your valuable inputs on the comment box is welcome 

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.


CHIEF COMPLAINTS

75 year old male resident of Nalgonda 

Pain in the abdomen since 2 months 

Abdominal distension since 1 month 

Decreased appetite since 1 week 

Swelling of lower limbs since 3 days 

Decreased urine output since 3 days 

HISTORY OF PRESENTING ILLNESS 

Patient was apparantly asymptomatic 2 months back , then he developed pain in the abdomen which was diffuse, intermittent. 

Then he noticed abdominal distension since 1 month which is insidious in onset, gradually progressive to the present size 

History of decreased apettite since 1 week 

Swelling of lower limbs since 3 days pitting type edema 

Decreased urine output since 3 days decreased for 2 to 3 episodes per day  , 

History of constipation since 1 month 

History of weight loss about 5-6 kgs in past 2 months 

No history of loose stools 


Patient presented with similar complaints 1 month back came  to the hospital where he was diagnosed as ascites secondary to decompensated liver disease 

Ascitic fluid tap was done at that time.

At that time suspected hepatocellular carcinoma and was referred to MNJ hospital  where liver biopsy was done showed no malignancy and was asked for repeat biopsy.

Now he again presented 3 days back with abdominal distension progressive associated with shortness of breath aggrevated on lying down relieved on sitting .

Decreased urine output 1 to 2 episodes per day yellow dark colour not associated with burning micturation ,frequency and urgency

History of one episode of vomiting containing food particles.

PAST HISTORY 

No history of Diabetes mellitus, hypertension, epilepsy, asthama TB, thyroid disorders.  

FAMILY HISTORY

Not significant 

PERSONAL HISTORY

Diet - mixed

Apettite - decreased

Sleep - distrubed 

Bowel and bladder movements - decreased 

Addiction - Alcohol occasionally

Allergies no 

DRUG HISTORY 

Using analgesics for leg pain since 1 year

GENERAL EXAMINATION

Patient is conscious, coherent , coperative

Moderately built and nourished 

Pallor present

Icterus present 


Cyanosis, clubbing, lymphadenopathy absent 


Pedal edema present pitting type 

 


Head to toe examination 

Hair normal 

Oral cavity  no fetor heapticus 

Skin normal 

No spider angioma 

Nails normal 

No flapping tremors 


VITALS 

Afebrile

Pulse rate -120 bpm 

Blood pressure - 130/80 mm Hg 

Respiratory rate - 20 cpm 

GRBS - 102 mg 

SYSTEMIC EXAMINATION 

ABDOMINAL EXAMINATION 

Inspection 

Abdomen distended with flank fullness seen 

Umbilicus central 

No scars and sinuses 

No engorged veins 




Palpation

No local raise of temperature

No tenderness 

Liver and spleen couldnot be palpable due to distention 

Percussion 

Shifting dullness present

Fluid thrill absent

Percussion

Liver borders 

Upper border - 5th intercostal space 

In midclavicular space 

Lower border not elicited

Ascultation 

Bowel sounds heard



Weight 65 kg 
Abdominal girth 97 cm 

CARDIOVASCULAR SYSTEM
 
On Inspection

Shape of the chest elliptical 

No raised Jvp 

Apical impulse - not seen 

Precordial bulge not seen 

No visible sinuses , scars , engorged veins , pulsations 

On Palpation

Apex beat felt at left 5th intercostal space in mid clavicular line 

No thrills and parasternal haeves 

On Auscultation:- 

S1 ; S2 heard ; no murmurs 

RESPIRATORY SYSTEM

Inspection: 

Shape of the chest elliptical

Equal chest movements

Trachea appears to be central 

Palpation

Inspectory findings confirmed

Bilateral equal chest expansion

Trachea centre 

Percussion

Resonant in all areas 

Ascultation: 

Bilateral air entry present

Normal vesicular breath sounds 

CENTRAL NERVOUS SYSTEM

Higher mental functions - normal 

Cranial nerves intact 

Sensory system - pain , temperature, pressure , vibration intact 

Motor system : 

Tone - normal in upper and lower limb 

Power               Right     left 

Upper limb.      5/5       5/5 

Lower limb       5/5      5/5 

Reflexes           Right.    Left 

Biceps               ++          ++ 

Triceps              ++.         ++

Supinator         ++.         ++ 

Knee                  ++.          ++ 

Ankle                  ++          ++ 

Plantar               ++.          ++

Cerebellum intact 

No meningeal irritation 

INVESTIGATION

HAEMOGRAM

Haemoglobin -8.6 gm/ dL 

Total count -19,400 cells/ mm3 

Neutrophils -83% 

Lymphocytes -10% 

 Esnophils  - 3% 

Monocytes 4% 

PCV - 26 vol % 

MCV - 92.2%

MCH 30.5 pg 

MCHC -33.1 % 

RDW - CV - 19.6% 

RDW - SD -65.4 

RBC count - 2.6 million / mm3 

Platelet count -160 lakhs/ mm3 

Normochromic normocytic anaemia with  neutrophils and leucocytosis 

Serum creatinine

3.5 mg/dl 

Electrolytes 

Sodium - 125 mEq/L 

Potassium - 4.4 mEq/L 

Chloride -94 mEq/L 

Blood urea 

140 mg /dL 

Random blood sugar - 91mg /dL 

Liver function test 

Total bilirubin - 11.58mg/dL

Direct bilirubin - 9.45mg/dL 

SGOT -597 IU / L

SGPT - 117 IU /L 

Alkaline phosphatase -628 IU/L 

Total proteins -5.6 gm/dL 

Albumin -2.23gm/ dL 

A/G ratio -0.66

PTT -22 sec 

INR -1.62 

APTT - 41 sec 

Ultrasonography

Liver size increased 

Irregular and nodular border of liver altered echotexture with hepatomegaly 

Gall bladder contracted 

Pancreas - head and body visualized 

Spleen - normal 

Kidney - normal 

Aorta - normal 

Interpretation - hepatomegaly and gross ascites 

ASCITIC FLUID TAP 

Done yesterday



ASCITIC FLUID

LDH 153 IU/ L 

Ascitic fluid sugar -73 mg/dL 

Ascitic fluid protein -1.4 g/ dL 

Ascitic fluid amylase - 37.7 IU/L 

Ascitic albumin -0.67 

SAAG high 

Total cell count 550 

Neutrophils 98%

Lymphocytes 2%

PROVISIONAL DIAGNOSIS

Ascites secondary to decompensated liver disease 

Heart failure with preserved ejection fraction (58%) 

TREATMENT

IV fluids NS -30ml/ hr 

Inj.lasix -40 mg / bd 

Fluid restriction < 2L / day 

Salt restriction <1.2gm/ day 

Inj. Cefotaxime - 2gm IV / TID 

Syp. Lactulose -30 ml po/ bd 





Comments

Popular posts from this blog

A 40 YEAR OLD MALE WITH ALTERED MENTAL STATUS

Sripadi Shirisha Rollno151