SHORT CASE - FINAL PRACTICALS GENERAL MEDICINE
NAME : M. NAGA VARSHA
BATCH : 2017
HALL TICKET NO. : 1701006102
This is an online E-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.
This E log book also reflects my patient centered online learning portfolio and your valuable comments on comment box is welcome.
I've 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 a diagnosis and treatment plan.
FOLLOWING IS THE VIEW OF MY CASE
50 year old male, farmer by occupation, resident of Yadadri, came to the hospital with the following chief complaints --
- Distended abdomen - from 7 days
- Pain abdomen- from 7 days
- Pedal edema- from 5 days
- Breathlessness- from 4 days
- insidious in onset,
- gradually progressive,
- aggravated in last 4 days and progressed to the present
- insidious in onset,
- gradually progressive,
- colicky type in the epigastrium and right hypochondrium
- Grade II since 3 days
- insidious in onset,
- Gradually progressive,
- pitting type
- bilateral
- below knees
He also complained of shortness of breath since 4 days - MRC grade 4
- Insidious in onset
- Gradually progressive
- Aggravated on eating and lying down
Patient is a known alcoholic since 20 years, he stopped 6 months back. Ascites increased after his last drink on 29th May, 2022.(beer and toddy)
- NO history of similar complaints in the past.
- Not a known case of Diabetes, Hypertension, Tuberculosis, Asthma, hypothyroidism/hyperthyroidism, COPD, and blood transfusions.
- no history of previous surgeries'
- Diet: mixed
- Appetite: reduced
- Bowel habits: frequency of urine is reduced since 2 days
- Bladder habits: constipation since last 4 days
- Sleep: disturbed
- Addictions:
- Beedi smoker: for past 30 years. 4-5 beedis per day
Alcohol
- Whiskey-90 ml, 2 times a week, since 5 years
- Built and nourishment: moderately built and moderately nourished
- Pallor: No pallor
- Icterus: No icterus
- Cyanosis: No cyanosis
- Clubbing: No clubbing
- Generalized lymphadenopathy: No generalized lymphadenopathy
- Pedal edema: Grade II bilateral pedal edema
- Shape of the abdomen: globular
- Distension of abdomen: distended
- Flanks: full
- Umbilicus:
- Shape: everted
- Position: central
- Movements of abdominal wall - moves with respiration
- Skin is smooth and shiny
- No scars, sinuses, distended veins, striae.
- Local rise of temperature present.
- Tenderness present - epigastrium.
- Tense abdomen
- Guarding present
- Rigidity absent
Fluid thrill positive
- Liver not palpable
- Spleen not palpable
- Kidneys not palpable
- Lymph nodes not palpable
PERCUSSION:
- Liver span : not detectable
- Fluid thrill: felt
AUSCULTATION:
- Bowel sounds: heard in the right iliac region
- The chest wall is bilaterally symmetrical
- No dilated veins, scars or sinuses are seen
- Apical impulse or pulsations cannot be appreciated
- Apical impulse is felt in the fifth intercostal space
- No parasternal heave felt
- No thrill felt
- Right and left borders of the heart are percussed
- S1 and S2 heard
- Shape- elliptical
- B/L symmetrical ,
- Both sides moving equally with respiration .
- Trachea - central
- Expansion of chest is symmetrical.
- Vocal fremitus - normal
- resonant bilaterally
- bilateral air entry present.
- Normal vesicular breath sounds heard.
CNS EXAMINATION:
- Conscious
- Speech normal
- Cranial nerves: normal
- Sensory system: normal
- Motor system: normal
Reflexes: Right. Left.
Biceps. ++. ++
Triceps. ++. ++
Supinator ++. ++
Knee. ++. ++
Ankle ++. ++
Gait: normal
Hemogram :
Hemoglobin : 9.8 g/dl
TLC : 7,200
Neutrophils : 49%
Lymphocytes : 40%
Eosinophils : 1%
Basophils : 0%
PCV : 27.4%
MCV : 92.3 fl
MCH : 33 pg
MCHC : 35.8%
RDW-CV : 17.6%
RDW-SD : 57.8 fl
RBC count : 2.97 millions/mm3
Platelet count : 1.5 lakhs/mm3
Smear : Normocytic normochromic anemia
Liver function tests:
Total Bilirubin : 2.22 mg/dl
Direct Bilirubin : 1.13 mg/dl
AST : 147 IU/L
ALT : 48 IU/L
ALP : 204 IU/L
Total proteins : 6.3 g/dl
Serum albumin : 3 g/dl
A/G ratio : 0.9
- ESR :
15mm/1st hour
- Prothrombin time : 16 sec
- APTT : 32 sec
- Serum electrolytes :
Sodium : 133 mEq/L
Potassium : 3 mEq/L
Chloride : 94 mEq/L
- Blood Urea : 12 mg/dl
- Serum Creatinine : 0.8 mg/dl
- Ascitic fluid :
Protein : 0.6 g/dl
Albumin : 0.34 g/dl
Sugar : 95 mg/dl
LDH : 29.3 IU/L
SAAG : 2.66 g/dl
- Serology :
HbsAg : Negative
HCV : Negative
HIV : Negative
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