General Medicine - Final practicals-short case

 June 08,2022

K. Tejasree

1701006075

This is an online E-log book to discuss our patient de-identified health data shared after taking his/ her guardians sign informed consent

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aim to solve those patient clinical problem with collective current best evidence based inputs.

This E-log also reflects my patient centered online learning portfolio.

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I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a  diagnosis and treatment plan.

CASE:

A 50 years old patient, who is a farmer by occupation, resident of pochampally has presented to the casualty  on 02-06-2022 with the chief complaints of

• Abdominal distension since 8 days
• Pain in the abdomen since 8 days
• Pedal edema since 6 days

History of present illness:

Patient was apparently asymptomatic 6 months back, then he developed jaundice for which he was treated by a local private practitioner. 

15 days back he consumed more than the usual amount of alcohol following which he started experiencing some discomfort and since 4 days developed abdominal distension which was insidious in onset, gradually progressive and progressed to present size.

It is associated with pain in epigastrium and right hypochondrium.

Patient complained of bilateral pedal edema of grade 2 below the kneee since 3 days which was insidious in onset, gradually progressive, pitting type, increased as the day progressed and had no relieving factors.

Associated symptoms : shortness of breath since 3 days.

No history of nausea and vomiting.

No history of chest pain, exercise intolerance.

No history of evening rise of temperature, cough, night sweats.

No history of hematemesis, dilated veins, hemorrhoids, melena. 

No history of facial puffiness, generalized edema. 

PAST HISTORY :

No history of similar complaints in the past.

Patient is not a known case of Diabetes mellitus, Hypertension, Tuberculosis, Asthma, Epilepsy, Thyroid disease.

There is no history of blood transfusion or hospital admission.

PERSONAL HISTORY :

Diet : Mixed

Appetite : Decreased

Sleep : Adequate

Bowel and bladder movements : Urine frequency is reduced since 2 days and patient has an history of constipation.

Addictions : Patient is a chronic smoker and smoked 4-5 bidis per day since past 30 years (Pack years=Number of cigarettes x years of smoking/20; 5x30/20 = 7.5)

Patient consumes alcohol occasionally (whenever he gets tired from work) - 90 ml of whiskey (previously he was a chronic alcoholic but stopped consuming regularly 6 months back). 

Patient consumes toddy occasionally 

FAMILY HISTORY :

No significant family history.

HISTORY OF ALLERGIES :

No known food or drug allergies.

GENERAL PHYSICAL EXAMINATION :

Patient is conscious, coherent, co-operative and well-oriented to time, place and person.

Patient is moderately built and is moderately nourished.

There is pedal edema of grade 2.

Icterus is present.

There is no pallor, cyanosis, clubbing, lymphadenopathy.

Vitals :

Temperature : Afebrile

Pulse rate : 90 bpm, regular, normal volume.

Respiratory rate : 22 cpm

Blood pressure : 130/90 mm Hg Right arm in sitting position 

GRBS : 90 mg/dl

O2 saturation : 98%

SYSTEMIC EXAMINATION :

Per abdomen :

On Inspection :

Abdomen appears to be distended and the umbilicus is everted. 

Skin is smooth and shiny.

There are no abnormal swellings, discoloration, scars, sinuses, fistulae, venous dilatations.

On palpation :

There is no local rise of temperature.

Tenderness is present in the epigastrium.

No hepatomegaly. No splenomegaly.

Guarding is present.

Rigidity is absent.

Fluid thrill is positive. Fluid thrill

Kidney not palpable.

On Percussion :

Tympanic note is heard on the midline of abdomen and a dull note is heard on the flanks in supine position. 

Shifting dullness : Positive 

Liver span could not be detected.

No renal angle tenderness.

Auscultation :

Bowel sounds are decreased.

No bruits could be heard.

Cardiovascular System : S1, S2 heard

Respiratory System : Normal vesicular breath sounds heard

Central Nervous System : Conscious; Speech normal ; Motor and sensory system examination is normal, Gait is 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

3. ESR :

15mm/1st hour

4. Prothrombin time : 16 sec

5. APTT : 32 sec

6. Serum electrolytes :

Sodium : 133 mEq/L

Potassium : 3 mEq/L

Chloride : 94 mEq/L

7. Blood Urea : 12 mg/dl

8. Serum Creatinine : 0.8 mg/dl

9. LFTs :

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

10. 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

11. Ascitic Fluid Cytology :

12. Ascitic fluid culture and sensitivity report :

13. Ultrasound :

Coarse echotexture and irregular surface of liver - Chronic liver disease

Gross ascites

Gallbladder sludge

14.X-ray

PROVISIONAL DIAGNOSIS :

Decompensated Chronic liver disease with ascites most likely etiology is alcohol. 

TREATMENT :

Drugs :

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

Ascitic fluid tapping : 

Ascitic fluid was tapped twice (2-06-2022 and 6-06-2022)