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:
A 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
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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