GENERAL MEDICINE FINAL PRACTICAL SHORT CASE

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HALL TICKET : 1701006073

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.

CASE DISCUSSION:

50 years old gentleman, farmer by occupation, resident of Yadadri Bhuvanagiri district came to the hospital with the following cheif complaints


CHIEF COMPLAINTS:

Distension of abdomen since 7 days

Pain in the abdomen since 4 days and

Pedal edema since 3 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. After that he was normal till last week.

He developed distension of abdomen 7 days back, which is insidious in onset, gradually progressive, aggravated in last 4 days and progressed to the present size.

He complaints of abdominal pain from last 3 days which is insidious in onset, gradually progressive, colicky type in the epigastrium and right hypochondrial regions .

He also complaints of swelling in both feet  since 3 days which is insidious in onset, gradually progressive, pitting type.


NO history of hemetemesis, melena, vomitings, nausea

NO history of bulky stools, black tarry and clay colored stools

NO history of fever with chills and rigor

NO history of anorexia, facial puffiness, generalised edema

NO history of evening rise of temperature, cough, night sweats

NO history of orthopnea, palpitations 

NO history of loss of weight


PAST HISTORY:


NO history of similar complaints in the past.

Not a known case of Diabetes, Hypertension, Tuberculosis, Asthma, epilepsy, hypothyroidism/hyperthyroidism, COPD, CAD and blood transfusions. 


FAMILY HISTORY:


None of the patient's parents, siblings or first degree relatives have or had similar complaints or any significant comorbidities.


PERSONAL HISTORY:

Appetite: reduced

Diet: mixed

Bowel habits: frequency of urine is reduced since 2 days

Bladder habits: constipation since last 4 days

Sleep: Adequate 

Addictions:

Beedi smoker: for past 30 years. 4-5 beedis per day

Pack years= no. of cigarettes×years of smoking/20

Number of beedis = numbr of cigarettes/4

Therefore, 

Pack years = 5/4×30/20

Pack years = 1.88 pack years


Alcoholic: chronic alcoholic previously 

From last one year, occasional alcoholic - consumes 90ml of whiskey 

Toddy: occasionally 


GENERAL PHYSICAL EXAMINATION:

Patient is conscious, coherent and cooperative.

Examined after taking vaild informed consent in a well enlightened room.


Built and nourishment: moderately built and moderately nourished 

Pallor: No pallor

Icterus: present 

Cyanosis: No cyanosis 

Clubbing: No clubbing 

Generalised lymphadenopathy: No generalised lymphadenopathy 

Pedal edema:  bilateral pedal edema







VITALS:


Temperature: afebrile

Pulse rate: 90bpm, regular rhythm, normal volume

Respiratory Rate: 16cycles per minute

Blood Pressure: 130/90 mm of Hg in right arm in sitting position

GRBS: 90mg/dl

SpO2: 98% at room air


Tremors: present




SYSTEMIC EXAMINATION:


PER ABDOMINAL EXAMINATION:


INSPECTION: 9 regions


Shape of the abdomen: globular

Distension of abdomen: distended

Flanks: full

Umbilicus: 

       Shape: everted

       Position: central

       Herniations: absent

       Discharge: absent

Skin over abdomen: smooth and shiny

No pigmentations, discolorations, scars, sinuses, fistulae, engorged veins, visible pulsations, hernial orifices, 


PALPATION: 


No local rise of temperature 

Tenderness: present in the epigastrium region

Hepatomegaly: absent

Splenomegaly: absent

Guarding: present 

Rigidity: absent

Renal angle tenderness: absent

No rebound tenderness

No visible peristalsis 

FLUID THRILL(with extended legs): POSITIVE 

PERCUSSION:




In supine position,

  Tympanic note - heard at midline of the abdomen 

  Dull note - heard at flanks

Shifting dullness: POSITIVE 

FLUID THRILL: POSITIVE

Liver span : could notbe detected


AUSCULTATION:


Bowel sounds: decreased

No bruits


CARDIOVASCULAR SYSTEM:


First and second heart sounds heard normal. No murmurs


RESPIRATORY SYSTEM: 


Normal vesicular breath sounds heard. No adventitious sounds. Bilateral air entry present. 


CENTRAL NERVOUS SYSTEM: 


HIgher mental functions- normal

No focal neurological deficit 

No facial asymmetry. All reflexes are normal.



INVESTIGATIONS:


1. 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


2. Serology : 

HbsAg : Negative

HIV : Negative

Prothrombin time : 16 sec



Ascitic fluid : 


Protein : 0.6 g/dl

Albumin : 0.34 g/dl

Sugar : 95 mg/dl




Blood Urea : 12 mg/dl
ESR: 15mm/1st hour


LFT:


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





Serum electrolytes :

Sodium : 133 mEq/L

Potassium : 3 mEq/L

Chloride : 94 mEq/L
LDH : 29.3 IU/L

Serum Creatinine : 0.8 mg/dl
APTT : 32 sec


SAAG : 2.66 g/dl







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 



ASCITIC FLUID CULTURE AND SENSITIVITY REPORT:

ZN staining: No acid fast bacilli seen.

Few epithelial cells with no inflammatory cells seen. No organisms seen.

No growth after 48 hours of aerobic incubation




ULTRASONOGRAPHY:


Coarse echotexture and irregular surface of liver - Chronic liver disease

Gross ascites

Gallbladder sludge



ELECTROCARDIOGRAPHY:





CHEST RADIOGRAPHY:



ASCITIC FLUID TAPPING: Done twice 


















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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