1801006168 long case
March 20 2023
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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.
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
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
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
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