1801006112 - LONG CASE

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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT.    

This E blog also reflects my patient centered 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 plan 

Chief Complaints:

A 28 year old male resident of Nalgonda , daily wage worker came to OPD with cheif complaints of 

Abdominal distension since 15 days 

Yellowish discoloration of eyes since 15 days 

Bilateral leg swellings since 15 days

Shortness of breath since 10 days 

History of present illness:

The patient was apparently asymptomatic 15 days back then he developed abdominal distention that increased on consuming food and decreased on passing stools 

 He a has bilateral , lower limb , below knee, pitting type of edema since 15 days 

He has shortness of breath grade 3 since 10 days 

 Patient has loss of appetite since 2 days.  

No history of pain in abdomen , melena , hemetemesis .

No history of chest pain , cough ,cold .

No history of orthopnea , paraxysomal nocturnal dysnpea 

No history of episgastric and retrosternal burning sensation . 

No history of decreased urine output, facial puffiness , burning micturation .

No history of confusion , drowsiness 

Past history:

5 months back he had yellowish discoloration for 3 days and fever which is high grade , not associated with chills and rigor , no evening rise of temperature , he went to hospital and took medication for a week 

Symptoms were subsided after a week then he started consuming alcohol again 180 ml per day

Not a known case of diabetes,hypertension,asthma,Tb,CAD.

Personal history:

Diet : Mixed 

Appetite : Decreased 

Sleep : normal

Bowel and Bladder moments : Constipation is seen

Addictions - consumes alcohol , 180 ml per day since 5 years 

Family history:

Not significant.

General physical examination:

Patient is conscious ,coherent and cooperative and well oriented to time, place and person.

moderately built and nourished.

Pallor-absent

Icterus-present

Cyanosis -absent

Clubbing-absent

Lymphadenopathy-absent

Edema- bilateral , pitting edema 

Vitals : 

Temperature: 98.2 c 

Pulse rate : 95bpm

Respiratory rate : 22cpm 

Blood pressure: 130/80mmhg

Spo2 : 98%

GRBS : 120mg/dl 

Systemic examination: 

PER ABDOMEN  - 

Inspection- 

Abdomen is distended , flanks are full, umbilicus is slit like , skin is stretched ,  dilated veins present , no visible peristalsis , equal symmetrical movements in all quadrants with respiration , external genetilia normal 

Palpation -  

There is no local rise in temperature, No tenderness, all inspectory findings are confirmed by palpation, no rebound tenderness , gaurding , rigidity , No organomegaly 

Percussion - 

Fluid thrill present 

Auscultation-

Bowel sounds heard 

CVS : 

Inspection-

Chest is  symmetrical , no dilated veins , scars and sinuses seen 

Palpation - 

Apical impulse felt at left 5th inter coastal space medial to mid clavicular line 

Auscultation- S1 , S2 heard , no murmurs 

RESPIRATORY SYSTEM: 

Inspection- 

Chest is symmetrical, trachea is central 

Palpation - 

Trachea is central ,

Bilateral chest movements equal , 

Percussion - resonant at 9 areas 

Auscultation- 

Normal vesicular breath sounds heard 

CENTRAL NERVOUS SYSTEM: 

Higher mental functions - normal memory intact

cranial nerves :Normal

sensory examination:

Normal sensations felt in all dermatomes

motor examination-

Normal tone in upper and lower limb

Normal power in upper and lower limb

Normal gait

reflexes-

Normal reflexes elicited- biceps, triceps, knee and ankle reflexes elicited

cerebellar function

Normal function

Provisional diagnosis : ascites secondary to alcoholic liver disease 

Investigations : 

Hemogram -

Hb- 13.2gm/dl

Total leucocyte count - 5000cells /mm3

Neutrophils - 71%

Lymphocytes -22%

RBC - 4.8 million /mm3

Ascitic tap - 

Appearance - clear , straw coloured 

SAAG - 1.79 g/dl

Serum albumin - 2.01 g/dl

Ascitic albumin - 0.22 g/dl

Ascitic fluid sugar - 166mg/dl

Ascitic fluid protein - 2.1 g/dl

Ascitic fluid amylase - 20.8 IU /L

LDH : 150IU/L

Total cell count - 150

Lymphocytes - 90%

Neutrophils - 10%

Liver function tests - 

Total bilirubin - 4.75mg/dl 

Direct bilirubin - 2.11mg/dl

SGOT(AST) - 178 IU/L

SGPT(ALT) - 50 IU/L

ALP- 255IU/L

Total protein - 6.2 gm /dl

Albumin - 2.01 gm/dl

A:G ratio - 0.48 

PT - 15 seconds

INR - 1.4 

aPTT - prolonged 

CUE:

Appearance - clear 

Albumin - trace 

Sugars - nil

Pus cells - 2to 4 

Epithelial cells - 1 to 3

RBC - nil 

RFT :

Blood urea - 20mg/dl

Creatinine - 0.9mg/dl

Serum electrolytes :

Sodium - 139 meq /L

Potassium - 4 meq/L

Chloride - 104meq/L

USG : 

Impression-normal size , altered echo texture , surface irregularities suggestive of  chronic liver disease present 

Xray :

Final diagnosis: ascites secondary to chronic kidney disease

Treatment: 

1. Fluid restriction 

2. Salt restricted normal diet 

3. Inj.VITAMIN K 1 ampoule in 100 ml NS OD 

4. Inj.THIAMINE 1amp in 100ml NS OD

5. Inj.PAN 40mg BD

6.Inj.ZOFER 4mgTID

7.Syrup LACTULOSE 15ml 30 mins before food TID

8. Inj.LASIX 40 mg BD