1801006163 Long Case

1801006163 Long Case

1801006163 LONG CASE

March 2023

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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 competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
Patient and his/her attenders have been informed and their consent has been taken.

33 Year old Male Labourer by occupation, resident of Nalgonda came

CHIEF COMPLAINTS
Abdominal distension since 2 months
Bilateral Pedal edema since 2 months

HISTORY OF PRESENTING ILLNESS

33 year old male got married 9 years back , separated from his wife and children since 5 years due to family issues about which he's not willing to tell .

After separation with his wife ,patient started taking whisky every day .
3 years back he had history of abdominal distension and pedal edema for which he visited local hospital and was diagnosed as liver disease and used medication for a while and stopped , he was diagnosed as diabetic back then and on treatment metformin 500 mg .

8 months back :
He had abdominal distension and yellowish discoloration of eyes and used herbal medication - he did not get any relief for it , his symptoms got aggravated then he visited other hospital with the complaints of abdominal distension and SOB at rest , back then he was diagnosed as DCMP secondary to alcoholism with Chronic Liver Disease with Alcohol Dependence Syndrome with DM - 2

Patient stopped taking medication since 2 months followed which he noticed bilateral pedal edema which was insidious in onset and gradually progressive and abdominal distension till the xiphisternum . Associated with yellowish discoloration of eye since 1 week insidious in onset, progressive, associated with itching & yellowish discoloration of urine from 4 days .
No history of vomitting, fever, abdomen pain, black tarry stools, hematemesis , facial puffiness, decreased urine output, altered sensoriom, tremors

PAST HISTORY
Known case of Chronic liver disease since 3 years
Known case of Diabetes since 2 years in medication tab metformin
Known case of Heart failure with Reduced Ejection Fraction since 8 months
Not a known case of hypertension, asthma, thyroid abnormalities.

FAMILY HISTORY
Not significant

PERSONAL HISTORY

Diet mixed
Appetite decreased since 5 days
Sleep adequate
Bowel and bladder movement regular

Known alcoholic since 5 years, consumes whiskey every day 60-90 ml

GENERAL EXAMINATION

Patient was conscious,coherent and cooperative. Moderately built and nourished

Icterus present

Pedal edema

No pallor, cyanosis, clubbing, lymphadenopathy

Vitals
Temperature - febrile (99.2 degree Fahrenheit)
PR - 112 bpm
RR - 22 cpm
BP - 110/70 mmHg
SPO2 - 99 % at RA

SYSTEMIC EXAMINATION
PER ABDOMEN
Inspection
Abdomen distended
Dilated veins present
Flanks are full
No scars sinuses

Palpation
No local rise of temperature
Mild tenderness over right hypochondrium
Abdomen tense
Liver and spleen not palpable
Percussion
Shifting dullness present
Fluid thrill present
Auscultation
Bowel sounds not heard clearly

CARDIOVASCULAR SYSTEM
Inspection
Shape of chest elliptical
No precordial bulge
Palpation
Apical impulse at left 6th intercoastal space lateral to midclavicular line
No parasternal haeve
Auscultation
Apex beat at left sixth intercoastal space lateral to mid clavicular line
S1, S2 heard
No murmurs

RESPIRATORY SYSTEM
Inspection
Shape of chest elliptical
Equal chest movement
Trachea appears to be central
Palpation
Inspectory findings confirmed
Bilateral equal chest expansion
Trachea central
Percussion
Resonant in all areas
Auscultation
Bilateral air entry present
Normal vesicular breath sounds heard

CENTRAL NERVOUS SYSTEM

Higher mental function - conscious, coherent, come operative.
Recent, immediate, remote memory present
Speech normal

Cranial nerves intact

Sensory system
Pain, temperature, pressure intact
Fine touch, proprioception, vibration intact

Motor system
Tone - Normal in Right and left upper and lower limb

Power- Right Left

Upper limb 5/5 5 /5

Lower limb 5/5 5/5

Reflexes :

Biceps: Right 2+

Left: 2+

Triceps: Right 2+

Left: 2+

Supinator: Right 2+

Left: 2+

Knee: Right: 2+

Left: 2+

Ankle: Right: 2+

Left: 2+

Plantar: Right : Flexion

Left: Flexion

Cerebellum

Knee heel test present.
Able to do finger nose test.
Dysdiadokinesia absent
Rhomberg test negative

INVESTIGATION
Hemogram :
HB - 13
TLC - 12,100
N/L/E/M - 67 /20/10/3
PCV - 37.8
PLt - 3.13
RBC - 4.81

RFT :
Urea - 31
Creatinine - 0.7
Uric acid - 2.7
Calcium - 10
Phosphorous - 3.8
Sodium - 130
Potassium - 3.6
Chloride - 91

LFT :
TB - 7.26
DB -4.21
AST - 26
ALT - 17
ALP - 560
TP - 6.6
Albumin - 3.6
A/G ratio - 0.24

Ultrasound :
1.altered echotexture of liver with mild surface irregularity ?chronic liver disease
2.Raised echogenicity of B/L kidneys
3.Gall bladder wall edema
4.Gross ascites
5.Skin and subcutaneous tissue shows edematous changes in the anterior abdominal wall diffusely

Chest X Ray

DIAGNOSIS
Chronic liver disease with ascites with Dilated Cardiomyopathy with Reduced ejection fraction

Treatment :
1.fluid restriction <1.5 l /day
2.salt restriction <2.4 g/day
3.Tab Lasix 40 mg po/bd
4.Tab Aldactone 50 mg po od
5.Tab Met xl 12.5 mg po bd
6.Tab Thiamine 100 mg po bd
7.daily weight and abdominal girth monitoring
8.I/O charting
9.Monitor vitals -4th hourly
10.Grbs - 6th hourly
11.inj HAI s/c according to sliding scale

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