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 --

  1. Distended abdomen - from 7 days 
  2.  Pain abdomen- from 7 days
  3.  Pedal edema- from 5 days 
  4.  Breathlessness- from 4 days

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 6 months back then he developed jaundice and he was treated for jaundice by a private medical practitioner.

He developed distension of abdomen 7 days back,
  • insidious in onset,
  • gradually progressive,
  • aggravated in last 4 days and progressed to the present 
He complaints of abdominal pain from last 3 days 
  • insidious in onset,
  •  gradually progressive,  
  • colicky type in the epigastrium and right hypochondrium
He complains of swelling in both feet 
  • 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 bulky stools, black tarry and clay colored stools

NO history of fever with chills and rigor
No cough/sputum/hemoptysis
No chest pain


PAST HISTORY:

  • 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'

FAMILY HISTORY:

Not significance 

PERSONAL HISTORY :

  1. Diet: mixed
  2. Appetite: reduced
  3. Bowel habits: frequency of urine is reduced since 2 days
  4. Bladder habits: constipation since last 4 days
  5. Sleep: disturbed
  6. Addictions:
  • Beedi smoker: for past 30 years. 4-5 beedis per day

  • Alcohol 

                 - Whiskey-90 ml, 2 times a week, since 5 years

                        toddy - occasionally 


GENERAL PHYSICAL EXAMINATION:

Patient is conscious, coherent and cooperative.
Examined after taking valid informed consent in a well enlightened room.





  • 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  





                                











SYSTEMIC EXAMINATION: 

PER ABDOMINAL EXAMINATION: 

INSPECTION: 9 regions

  • 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.

  

                           



                               

PALPATION :

  • 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 


CARDIOVASCULAR SYSTEM- 

Inspection- 
  • The chest wall is bilaterally symmetrical
  • No dilated veins, scars or sinuses are seen
  • Apical impulse or pulsations cannot be appreciated 

Palpation-
  • Apical impulse is felt in the fifth intercostal space
  • No parasternal heave felt
  • No thrill felt

Percussion- 
  • Right and left borders of the heart are percussed 

Auscultation-
  • S1 and S2 heard

RESPIRATORY SYSTEM:

Inspection: 

  • Shape- elliptical 
  • B/L symmetrical , 
  • Both sides moving equally with respiration .

Palpation:

  • Trachea - central
  • Expansion of chest is symmetrical. 
  • Vocal fremitus - normal

Percussion: 

  • resonant bilaterally 

Auscultation:

  •  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 



INVESTIGATIONS


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




















ASCITIC FLUID CYTOLOGY:

Microscopy:
Cytology smear study shows few scattered lymphocytes, reactive mesothelial cells against a granular eosinophilic proteinaceous background.
No atypical cells are seen.
Impression: negative for malignancy 












ULTRASONOGRAPHY



CHEST XRAY








PROVISIONAL DIAGNOSIS:

This is a case of Decompensated Chronic liver disease with ascites, probably secondary to chronic alcoholism.



TREATMENT:

1. Inj. PANTOPRAZOLE 40 mg IV OD

2. Inj. LASIX 40 my IV BD

3. Inj. THIAMINE 1 Amp in 100 ml IV TID

4. Tab. SPIRONOLACTONE 50 mg BB

5. Syrup. LACTULOSE 15 ml HS

6. Syrup. POTCHLOR 10ml PO TID

7. Fluid restriction less than 1L/day

8. Salt restriction less than 2g/day











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