General medicine final practical short case

June 08, 2022

This is 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 patient's clinical problems with collective current best evidence based inputs .This e-log book also reflects my patient centered online learning portfolio and your valuable comments on comment box is welcome.

Vignatha 9th semester

roll no: 45

I've 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 a diagnosis and treatment plan.

CONSENT AND DEIDENTIFICATION :

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

This is a case of 50 years old patient, who is a farmer by occupation, resident of pochampally has presented to the casualty 7 days back with the chief complaints of

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

5Am-Wake up

Till 8AM- Field work

8AM- Breakfast (Rice)

1PM - lunch

6PM- reaches home

8PM - dinner

9PM - sleep

The Patient was apparently asymptomatic 6 months ago when he developed jaundice and was treated in a private hospital

His last consumption of alcohol was on 29th May 2022 which was when he drank more than usual

Then he developed abdominal distension which was insidious in onset and gradually progressive to the present size

There were no aggravating and relieving factors

It was associated with

1)pain abdomen in the epigastric and right hypochondriac region which is insidious in onset and diffuse to whole of the abdomen and gradually increased in intensity and is of colicky type

Pain is persistent throughout the day. No history of radiation to the back.

2) bilateral pedal edema below knees and is of pitting type, which was insidious in onset and gradually progressive throughout the day and is maximum in the evening and is not relieved by rest

No local rise of temperature and tenderness

Associated symptoms- shortness of breath since 4 days

There is no history of orthopnoea, palpitations.

No history of facial puffiness and haematuria.

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

No history suggestive of hemetemesis, melena, bleeding per rectum .

No raised JVP, basal lung crepitations.

No palpable mass per abdomen.

Past history

No history of of similar complaints in the past

Not a known case of Hypertension, Diabetes, asthma, epilepsy, TB
No previous surgical history

Personal history
Diet- Mixed
Appetite- Decreased since 10 days
Bowel and bladder movements- Regular
Sleep- Adequate
Addictions-
Patient is a chronic smoker since 30 years- 4to5 beedis/day
Alcohol - Consuming whisky since 20 years- 3 to 4 times per week (90 ml each time)
No history of drug or food allergies

Family history
No similar complaints in the family

General examination:
Done after obtaining consent, in the presence of attendant with adequate exposure
Patient is conscious, coherent, cooperative and well oriented to time, place and person
Patient is well nourished and moderately built
Pallor - absent
Icterus- present
Cyanosis- absent
Clubbing- absent
Pedal edema- present- bilateral pitting type.
Lymphadenopathy- absent .

Vitals
Temperature- Afebrile
Blood pressure- 120/80 mm of Hg
Pulse rate- 78 bpm
Respiratory rate- 16 cpm

Local examination
Abdominal examination:

Inspection
Shape of the abdomen- Distended
Umbilicus- everted
Movements of abdominal wall- moves with respiration
Skin is smooth, shiny
No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites
Palpation

Inspectory findings are confirmed
Tenderness is present in whole of the abdomen
Guarding and rigidity present
Fluid thrill positive
No hepatosplenomegaly

Percussion
Fluid thrill- felt
Liver span- Not detectable

Auscultation
Bowel sounds are heard

Cardiovascular system examination:
S1 and S2 sounds are heard
No murmurs

Respiratory system examination:
Bilateral air entry present
Normal vesicular breath sounds are heard

Central nervous system examination:
No focal neurological deficits

Investigations

Investigations:

Serology
HIV- Negative
HCV- Negative
HbsAg- Negative

Hemogram

Haemoglobin- 9.8 gm/dl

Total count- 7200 cells/cumm
Neutrophils- 49%
Lymphocyes- 40%
Eosinophils- 1%
Monocytes- 10%
PCV- 27.4 vol%
MCH- 33 pg
MCHC- 35.8%
RDW- 17.6
RBC count- 2.97 millions/cumm

Prothrombin time
Prothrombin time- 16 sec
INR- 1.11

Ascitic fluid protein sugar
Sugar- 95 mg/dl
Protein- 0.6 g/dl

Ascitic fluid for LDH
LDH- 29.3 IU/L

Blood Urea
Blood urea- 12mg/dl

ESR
ESR- 15mm/1st hour

LFT
Total bilirubin- 2.22 mg/dl
Direct bilirubin- 1.13 mg/dl
SGOT(AST)- 147 IU/L
SGPT(ALT)- 48 IU/L
Alkaline phosphate- 204 IU/L
Total proteins- 6.3 gm/dl
Albumin- 3 gm/dl

Serum electrolytes
Sodium- 133 mEq/L
Potassium- 3 mEq/L
Chloride- 94 mEq/L

Serum creatinine
Serum creatinine- 0.8 mg/dl

APTT
APTT test- 32 sec

SAAG
Serum albumin- 3 gm/dl
Ascitic albumin- 0.34 gm/dl
SAAG- 2.66

Provisional diagnosis:
Acute decompensated liver failure with ascites

Treatment:
1. Inj PAN 40 mg IV/OD
2. Inj LASIX 40mg IV/BD
3. Tab Spiranolactone 50mg/ BD
4. Inj Thiamine 1 amp in 100 ml NS IV/ TID
5. Syrup lactulose 15 ml/ TID
6. Abdominal girth charting 4th hourly
7. Fluid restriction <1L/ day
8. Salt restriction <2g/ day

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Vignatha