HALL TICKET NO: 1801006183

LONG CASE

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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.

CHIEF COMPLAINTS: 

A 35 yr old male came to opd with chief complaints of abdominal distenstion since 15 days , yellowish discoloration of eyes since 15 days , bilateral swelling of legs since 15 days , shortness of breath since 10 days .

HISTORY OF PRESENTING ILLNESS :

patient was apparently asymptomatic 15 days back then he developed abdominal distenstion which is insidious in onset and gradually progressive since 15 days and he has bilateral lowerlimb swelling below knee since 15 days .patient is having breathlessness for 10 days for regular household activities like using toilet, while brushing , walking within home , patient is having itching over all the body since 10 days .

patient has loss of apetite since 1 week .

NO history of abdominal pain.

NO histroy of chest pain , palpitations, orthopnea .

NO history of cough , hemoptysis .

No histroy of melena , hemetemesis .

NO history of epigastric and retrosternal burning sensation .

No histroy of facial puffiness , burning micturation, decreased urine output .

NO histroy of confusion , drowsiness.

PAST HISTORY:

patient has similar complaints in the past 5 months back and he developed yellowish discoloration of eyes for 3days ,fever was high grade , continuous not associated with chills and rigor , no evening rise of temperature, he went to hospital for 1 week and symptoms subsided after a week following which he continued consuming alcohol since then (180ml per day)

NOT a known case of diabetes, hypertension, asthma , TB , CAD.

PERSONAL HISTORY:

Diet :Mixed

Appetite : decreased 

Sleep :normal

Bowel and bladder : constipation is present 

Addictions: patient consuming alcohol 180 ml per day since 5 yrs. Non smoker.

FAMILY HISTORY:

NO similar complaints in the family.

GENERAL EXAMINATION:

patient is conscious,coherent, cooperative and well oriented to time ,place and person moderately built and nourished.

Pallor: absent

Icterus: PRESENT

cyanosis :absent 

clubbing : absent 

Edema : Bliateral pitting type of pedal edema is present.

lymphadenopathy:absent

VITALS:

Temperature: 98.4*C

BP: 100/70 mm Hg

pulse rate: 65 bpm

Respiratory rate :22cpm

SpO2: 98%

GRBS :120 mg/dl

STSTEMIC EXAMINATION 

PER ABDOMEN:

INSPECTION:

Abdomen is distended.

flanks are full.

umbilicus is slit like.

skin is stretched , dilated veins present,no visible peristalsis, equal symmetrical movements in all quadrants with respiration.

PALPATION :

No local rise of temperature, no tenderness 

All inspectory findings are confirmed by palpation, no rebound tenderness, guarding and rigidity .

No tenderness, spleen palpable in left hypochondrium.

PERCUSSION-Fluid thrill present 

AUSCULTATION: Bowel sounds are present 

CVS :

INSPECTION:

chest is symmetrical, no dialated veins , scars and sinuses seen 

PALPATION: Apical impulse felt at left 5th inter coastal space medial to mid clavicular line

AUSCULTATION: S1 ,S2 heard no murmurs .

RESPIRATORY SYSTEM: 

INSPECTION: 

chest is symmetrical, trachea is central 

PALPATION: 

Trachea is normal 

Bilateral chest movements are equal 

PERCUSSION:

Resonant in all 9 areas 

AUSCULTATION: 

Normal vesicular breath sounds heard.

CENTRAL NERVOUS SYSTEM:

Higher mental functions - normal memory intact

cranial nerves :Normal

sensory examination:

Normal sensations felt in all dermatomes

motor examination-

Normal tone in upper and lower limb

Normal power in upper and lower limb

Normal gait

reflexes-

Normal reflexes elicited- biceps, triceps, knee and ankle reflexes elicited

cerebellar function-

Normal function.

INVESTIGATIONS : 

Hemogram -

Hb- 13.2gm/dl

Total leucocyte count - 5000cells /cumm

Neutrophils - 71%

Lymphocytes -22%

RBC - 4.8 million /cumm

Electrolytes-

Sodium- 138mEq/l

Potassium - 4.4mEq/l

Chloride- 104mEq/l

Liver function tests - 

Total bilirubin - 4.75mg/dl 

Direct bilirubin - 2.11mg/dl

SGOT(AST) - 178 IU/L

SGPT(ALT) - 50 IU/L

ALP- 255IU/L

Total protein - 6.2 gm /dl

Albumin - 2.01 gm/dl

A:G ratio - 0.48

Ascitic tap - 

Appearance - clear , straw coloured 

SAAG - 1.79 g/dl

Serum albumin - 2.01 g/dl

Asctic albumin - 0.22 g/dl

Ascitic fluid sugar - 166mg/dl

Ascitic fluid protein - 2.1 g/dl

Ascitic fluid amylase - 20.8 IU /L

LDH : 150IU/L 

Cell count- 150 cells 

Lymphocytes 90%

Neutrophils 10%

PT - 15 seconds

INR - 1.4 

aPTT - prolonged 

CUE:

Appearance - clear 

Albumin - trace 

Sugars - nil

Pus cells - 2to 4 

Epithelial cells - 1 to 3

RBC - nil 

RFT :

Blood urea - 20mg/dl

Creatinine - 0.9mg/dl

X-RAY:

USG : 

Impression- liver normal size

Altered echotexture with surface irregularities present suggestive of chronic liver disease.

Mild spleenomegaly.

DIAGNOSIS

Alcoholic cirrhosis with portal hypertension.

Decompensated features are jaundice and ascitis .

currently no hepatic 

encephalopathy or hepatorenal syndrome .

TREATMENT PLAN:

1. Fluid restriction 

2. Salt restricted normal diet 

3. Inj.VITAMIN K 1 ampoule in 100 ml NS OD 

4. Inj.THIAMINE 1amp in 100ml NS OD

5. Inj.PAN 40mg BD

6.Inj.ZOFER 4mgTID.

7.Syrup LACTULOSE 15ml 30 mins before food TID.

8. Tab. Aldactone 50mg OD

9. Tab. LASIX 40mg BD.