1801006021 -short case

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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.

35 YR OlD MALE PATIENT , LORRY DRIVER BY OCCUPATION , RESIDENT OF ATTHAMPET ,CAME TO THE OPD WITH THE 

C/O Pain abdomen since 10days,

yellowish discolouration of urine since 8 days

Distension of abdomen since 6 days 

Bilateral lower limb swelling since 5 days .

HISTORY OF PRESENTING ILLNESS : 

Patient was apparently asymptomatic 10days ago  and then developed,abdominal pain ,which was insidious in onset and gradually progressive ,which was of dragging type and diffuse, No aggravating factors but relieved on medication and reccured on stoping medication ,but not relieved on leaning forward .

Yellowish discolouration of urine since 8 days, NOT  ASSOCIATED with any poor stream ,pyuria ,hematuria ,increased frequency , nocturia ,Burning micturition  but decreased urine output  present since 5days 

Abdominal distension 

and bilateral lower limbs edema  since 6days,which were insidious in onset and gradually progressive, pitting type of edema over bilateral lower limbs,till knees 

Pitting Type Of Edema  : 

Constipation since 5 days, Not associatied with passage of blood in stool /melena 

PAST HISTORY: 

No history of similar complaints in the past 

K/C/O DIABETES MELLITUS ,which was diagnosed 5 months ago and started on ORAL HYPOGLYCEMIC DRUGS ( pt couldnt remember the drugs names )

N/K/C/O HTN , EPILEPSY ,CAD,CVA ,TB ,ASTHMA

PERSONAL HISTORY: 

Sleep - Disturbed since 10days.

Diet - Mixed 

Appetite - Disturbed since 6 days

Bowel and bladder movements : IRREGULAR ( decreased urine output and Stools not passed since 5 days )  

Addictions : Alcoholic and chronic smoker since 10years 

GENERAL EXAMINATION:

Patient is drowsy not coherent and not co operative, moderately built and nourished.

Vitals at presentation 

Temp : Afebrile 

BP: 110/80mmHg 

PR: 86bpm 

RR: 20cpm 

SpO2 : 98%

Pallor - absent 

Icterus - present -

Cyanosis:- absent 

Clubbing - absent 

Lymphadenopathy : absent 

Edema : Present till knee level and of pitting type

 

PER ABDOMEN

Patient was examined after taking consent in a well lit room

ON INSPECTION 

Abdomen is distended

umbilicus is inverted 

Skin over abdomen is stretched and shiny  

No visible pulsations

Engorged veins - Present 

PALPATION : 

all inspectory findings confirmed 

No rise of temperature and tenderness 

No guarding and rigidity 

Liver and spleen are unable to palpate due to ascites.

PERCUSSION : 

Shifting dullness - Present 

Fluid thrills - Present 

Puddle sign cannot be elicited ,as pt is not cooperative 

AUSCULTATION :

Sluggish bowel sounds are heard 

No bruits

CVS :  S1 and S2 heard 

            no murmurs

CNS: No flapping tremors( Asterexis ) 

(Apraxia cannot be elicited as pt is not cooperative )

Apraxia Charting after 5 days of Hospital Stay : 

RS : bilateral air entry is present

INVESTIGATIONS: 

ASCITIC TAP DONE and fluid sent for analysis :

 

ASCITIC TAP DONE and fluid sent for analysis :

ABG : 

CT scan :  Showing Calcifications:

CT scan :  Showing Calcifications:

Chest Xray: 

USG REPORT: 

Enlarged liver with altered echotexture s/o CLD

gall bladder edema with sludge

Gross ascitis

Provisional Diagnosis : 

Chronic liver disease 2° to alcohol intake with Type II DM 

Alcohol dependence Syndrome 

Chronic pancreatitis 

MANAGEMENT:

) IV fluid NS 50 ml /hr 

2) inj lasix 40mg IV /BD 

3) T. Aldactone 50mg RT /OD

5) Syp . Lactulose 15ml RT /TID 

6) Salt and fluid restriction ; Salt < 2gm /day , fluid < 1.5 lit /day 

7) inj 3 amp KCL in 500ml NS over 5 hrs 

8) Weight and abdominal girth daily 

9) GRBS monitoring 2nd hrly 

10) vitals monitoring 4th hrly 

12) inj .Thiamine 200mg IV /BD 

13) 3-4 egg whites /day 

14) protein X powder 3-4 scoops in glass of milk RT/TID.

 Follow up:- 

Patient visited two times since December

Maintenance on 

*Udiliv- 300 

*Viboliv 

*Thiamine 

Abdominal distention and jaundice subsided.