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Dec14 2021
Name: P. Sai Krupa Sri
Roll no : 175
I've 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.
47 YEARS OLD MALE PATIENT WITH ABDOMINAL DISTENSION
Case Presentation
A 47 years old male patient resident of miryalaguda auto rickshaw driver by occupation came to the hospital with
Chief complaints:- of
• Abdominal distension since 4 days
• Decreased urine output since 4days
• Bilateral Pedal edema since 4days
History of present illness :-
Daily routine of the patient :
The patient used to getup at 5 in the morning and have breakfast then he used to go to work ( auto rickshaw driver since 10 years ).
Before that he used to work as hamali for 20 years.
He then return home by 5 in the evening and had a habit of consuming alcohol daily before eating which was 90ml since 30years.
Then he sleeps at around 10pm.
• Patient was apparently asymptomatic 6 months back later he developed abdominal distension, bilateral pedal edema and he also developed jaundice.
• he also observed that his urine output decreased
• Then he went to local hospital there he was informed that he had fluid in stomach and liver disease.
• ascitic tap was done and the fluid removed is approximately 1 liter. And he was given medication
• After using the medication 2 to 3 weeks jaundice was reduced and abdominal distension reduced.
• Then he was on medication for 5 months , started tapering gradually from 1 month.
He also consumed alcohol 2 to 3 times in this month (he completely stopped alcohol from 6 months ).
• 4 days ago he developed abdominal distension which is gradually progressive and painless associated with bilateral pedal edema of lower limbs grade 4.
• 4 days back he also developed decreased urine output.
And also complaint of burning micturation
No h/o hematuria
Past history :-
• 10 years back he was diagnosed with psoriasis and on medication since 10 years
He stopped using medication since 1 year.
He has been using ayurvedic medicine since last month
• 6 months back, he was diagnosed with HBsAg positive
• Not a K/C/O DM, HTN, TB, Epilepsy, Asthma.
Personal history:-
Diet : Mixed ( stopped eating meat since 6 months )
Appetite : Normal
Sleep : Adequate
Bowel movements: regular
Addictions : stopped consumption of alcohol 6months ago ( before he used to consume daily 90ml)
No known allergies
Family history :-
Not significant
General examination :-
Patient is conscious, coherent and cooperative.
He is well oriented to time, place and person.
He is moderately nourished.
Pallor- Present
Icterus- Present
No Cyanosis
No Clubbing
No Lymphadenopathy
Edema - Bilateral Pedal edema is present (pitting type) grade 4 .
Vitals :-
Temp. - 98.2 F
PR - 110 bpm
RR - 20 cpm
BP - 170/100 mmHg
SpO2 - 99% at RA
Systemic examination :-
CVS:-
Inspection - chest wall is bilaterally symmetrical
- No precordial bulge
- No visible pulsations, engorged veins, scars, sinuses, carotid artery was prominent
Palpation - JVP is not seen
Auscultation - S1 and S2 heard, apex beat is heard in the axillary line in 6th intercostal space
RESPIRATORY SYSTEM:-
- Position of trachea is central
- Bilateral air entry is normal
- Normal vesicular breath sounds heard
- No added sounds
PER ABDOMEN :-
Inspection:-
Shape of the abdomen - distended
Umbilicus - everted
All quadrants moving equally with respiration
No visible pulsations
No visible peristalsis
No striae
No prominent superficial veins are seen
No scars and sinuses
Palpation :-
Non tender
Percussion : -
Shifting dullness is present
Auscultation :-
Bowel sounds heard
Provisional diagnosis :
Decompensated chronic liver disease secondary to liver cirrhosis
Ascites
HBsAg positive status with psoriasis
Investigation :
ECG:
Ascitic fluid cell count :-
Sugar- 151 mg/dl
Proteins- 6.7
SAAG- 2.0
Since the SAAG ratio is high (>1.1) ascites could be because of portal hypertension.
USG :-
Colour Doppler 2d echo :-
Serology- HBsAg positive
CBP:
Hb- 12 gm/dl
TLC- 9300
Plt- 1.54 lakhs/cu. mm
LFT:
TB- 2.94
DB- 1.66
AST- 37
ALT- 24
ALP- 259
TP- 6.5
ALBUMIN- 2.4
A/G RATIO- 0.59
RFT:
UREA- 42 mg/dl
CREATININE- 1.8 mg/dl
SODIUM- 144 mEq/L
POTASSIUM- 4.2 mEq/L
CHLORIDE- 104 mEq/L
Serum albumin : 2.2gm/dl
Dermatology referral taken in view of Psoriasis.
Treatment given:
1. Inj. LASIX 40 mg I.V. BD
2. Tab. ALDACTONE 50 mg PO OD
3. Syp. LACTULOSE 10 ml PO BD
4. Fluid restriction <1 Litre/day
Salt restriction <2 gm/day
5. GRBS 12th hourly
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