long case
Chief complaints :
A 50 year old male came with complaints of
-Abdominal distension since 10 days
-Bilateral lower limb swelling since 8 days
HISTORY OF PRESENTING ILLNESS:
-Patient was apparently asymptomatic 10 days back then he had abdominal distension which was insidious in onset, gradually progressive not associated with pain ,no relieving and aggregating factors.
- He has associated bilateral pedal edema since 8 days ,which is pitting type extending from ankle to knee, more in the evening hours, gradually progressive.
-No history of fever
-No H/o hematemesis , melena , bleeding per rectum, constipation.
-No history of orthopnoea, paroxysmal nocturnal dyspnoea.
-No history of epigastric and retrosternal burning sensation
-No history of facial puffiness, decreased urine output , hematuria .
-No history of confusion, drowsiness or altered sleep rhythm.
PAST HISTORY:
6 months back , history of abdominal distension , bilateral pedal oedema,
for which he was admitted for 10 days which relieved with diuretics , abdominal paracentesis was done
No history of jaundice in the past
No history of blood transfusion, tattooing or injection drug abuse.
Not a known case of HTN , Diabetes , asthma , TB , epilepsy , CAD , thyroid diseases .
Personal history
He is a government employee who wakes up at 6 am ,does his daily routine and goes to his work . Most of the time he skips his breakfast and has lunch at around 2 pm to 3 pm and comes to home at around
6 pm.
Does his normal activities
At night:he consumes alcohol
This was his daily routine since 12 years .
He takes mixed diet
-Appetite : decreased since 6 days
-Sleep : adequate
-Bowel : regular
-Bladder :decreased urine output since 6 days
-Addictions :
chronic consumption of alcohol since 12 years daily , country liquor of 500 ml (nearly 110gm per day)
whisky of 150 ml per day (nearly 50gm per day)
Suggesting consumption of harmful dose of alcohol
- No h/o smoking
Family history
No history of similar complaints in any of his family members
GENERAL EXAMINATION
Patient was conscious,coherent and cooperative. Moderately built and nourished
-Pallor : present
- Icterus: absent
-Clubbing: absent
-Cyanosis: absent
-Lymphadenopathy: absent
-Edema : present
Bilateral
Pitting type
Painless
Extending upto the ankle
VITALS:
At presentation:
Temp : afebrile
BP : 110/90 mmHg in right arm, supine position
Pulse : 90 bpm
RR : 22cpm
Spo2 : 98% on room air
JVP is normal
Head to toe examination-
Hair is sparse
B/ l parotid enlargement - negative
No fetor hepaticus
No evidence of xanthoma and xanthelasma.
No gynaecomastia
Spider nevi - absent
No palmar erythema
No leuconychia
No duputryens contracture
Flapping tremors - absent
Axillary and pubic hair are normal
SYSTEMIC EXAMINATION
Gastrointestinal system examination
Oral cavity: normal
INSPECTION:
-Abdomen is uniformly distended
-dilated veins are seen
( Examined in standing position)
-Flanks are full
-Umbilicus appears flat
-No scars , sinuses
- No visible peristalsis
- Hernial orifices appear normal
PALPATION:
Done in supine position , with both lower limbs flexed and hands by side of body
Superficial palpation:
-No local rise of temperature , tenderness
-No guarding and rigidity
No local lymphadenopathy
-Abdominal girth : 92 cms
DEEP PALPATION
-Liver and spleen are not palpable.
- Shifting dullness present
- Fluid thrill absent
PERCUSSION:
Liver span -
upper border of liver dullness in 5 th intercoastal space in mid clavicular line, lower border could not be appreciated.
AUSCULTATION:
Bowel sounds were not clearly audible.
No bruit , venous hum or friction rub.
Examination of external genitalia
Appears normal
- No testicular atrophy.
RESPIRATORY SYSTEM:
-Bilateral air entry present
-Normal vesicular breath sounds heard ,
CARDIO VASCULAR EXAMINATION
-S1 S2 heard
-No murmurs
CENTRAL NERVOUS SYSTEM EXAMINATION
No focal neurological deficit.
PROVISIONAL DIAGNOSIS:
Chronic decompensated liver parenchymal disease
Etiology - ethanol
INVESTIGATIONS
CBP -
HB - 10.7
TLC - 19100,
PLT - 1.50 LAKH
LFT -
Total bilirubin - 1.63 mg/ dl
Direct bilirubin - 0.40mg/dl
SGOT - 34 IU/L
SGPT - 20 IU/L
ALP - 186 IU/L
Total protein - 5.4 gm/dl
Albumin - 2.06 gm/ dl
RBS- 70mg/dl
Ascitic fluid analysis -
SAAG - 1.74.
(Serum albumin - 2.01
Ascitic albumin - 0.36)
Ascitic LDH - 120 IU/ L
Ascitic sugar - 52 mg/ dl
Ascitic protein - 0.8 g/dl
Appearance - Clear
Neutrophil count - 405.
Total count - 675
RBCS - Present.
PT - 16 Sec.
APTT - 32sec.
INR - 1.11
HEPATITIS SEROLOGY
HbsAg -negative
Hcv - negative.
USG ABDOMEN
Impression- liver normal size
Altered echotexture with surface irregularities present suggestive of chronic liver disease
FINAL DIAGNOSIS
Ascites due to chronic liver disease.
MANAGEMENT
Ascitic tap for symptom relief
*Fluid restriction less than 1.5 L /day
*STRICT INPUT /OUTPUT CHARTING
• Salt restriction less than 2g/day
• Inj Lasix 40mg IV BD
• Syp lactulose 30ml PO
----------------------------------------------------------------------------------------------------------------------------------------------------
short case
13 YR OLD GIRL WITH PAIN ABDOMEN
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
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 COMPLAINT
A 13 yr female brought to causality at around 3:00am with h/o 5-6 episodes of vomitings , pain abdomen and in a drowsy state.
HOPI
Patient was apparently normal, one day ago, patient did not take take any insulin in the morning and had food and went to school. By evening pt reached home with complaint of abdominal pain and 3 episodes of vomiting.
Abdominal pain was sudden onset, progressive and no aggrevating and relieving factors.
Vomitings were non projectile , with food particles as content, non bilious , 6 episodes.
No history of fever, burning micturition, headache, cough.
Past history:
3 months back, then pt had fever and weakness for which she was admitted in hospital (miryalaguda) and was diagnosed as diabetes mellitus.
Patient was on insulin 16 units morning,12 units evening for 10 days,dose was increased to 18 units morning and 16 units evening.
PAST HISTORY
K/c/o type 1 diabetes mellitus since 3 months,
on insulin( HAI ) 18 units,16 units
No history of hypertension, cyanosis,CAD ,epilepsy, TB , asthma .
TREATMENT HISTORY
Insulin (HAI)since 3 months
PERSONAL HISTORY
She wakes up at 7am.
8am she takes her insulin
9am goes to school
6pm returns home does her homework
Diet : mixed
Appetite: increased ,and she refused to follow diet and consumes rice 3 times a day
Sleep adequate
Bowel movements regular
Bladder movements : increased frequency of micturition
No known allergies
No addictions
Family history -- No relevant history
GENERAL EXAMINATION
Pt was drowsy
GCS : E3V4M6
No pallor, icterus, cyanosis, clubbing, generalized lymphadenopathy and Edema
VITALS at admission
Bp 100/55mmhg
Pulse 120bpm
RR 55 cpm
Temperature 98.7
SpO2 99
Grbs 650 mg/dl
SYSTEMIC EXAMINATION
CNS
She is in a confused state,
CRANIAL NERVE EXAMINATION: INTACT
SENSORY EXAMINATION : NORMAL
MOTOR EXAMINATION
Upper limb lower limb Rt lt Rt lt
Tone
N N N N
Power
5/5 5/5 5/5 5/5
Reflexes right left
Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Knee ++ ++
Ankle ++ ++
Cerebellar signs : normal
Absent meningeal signs
Abdominal examination
INSPECTION
Normal in shape
Umbilicus is normal
No scars or engorged veins are present
PALPATION:
No local rise of temperature
Tenderness in epigastric region and around umbilicus
No Hepatomegaly
No Splenomegaly
PERCUSSION:
Normal liver span
No shifting dullness
AUSCULTATION:
Bowel sounds heard
RESPIRATORY SYSTEM EXAMINATION
Inspection -
Chest is symmetrical
Trachea appears midline
No Scars, sinuses, Dilated Veins
Palpation -
Trachea is in Midline
No tenderness, local rise in temperature
Tactile Vocal Fremitus - Normal in all 9 areas
Percussion -
Percussion
Right Left
Supra clavicular:
resonant resonant
Infra clavicular:
resonant resonant
Mammary:
resonant resonant
Axillary:
resonant resonant
Infra axillary:
resonant resonant
Suprascapular:
resonant resonant
Infra scapular:
resonant resonant
Inter scapular:
resonant resonant
Auscultation
Right. Left
Supra clavicular NVBS NVBS
Infra clavicular: NVBS NVBS
Mammary:
NVBS NVBS
Axillary:
NVBS NVBS
Infra axillary:
NVBS NVBS
Supra scapular:
NVBS NVBS
Infra scapular:
NVBS NVBS
Inter scapular:
No added sounds
Vocal Resonance in all 9 areas
Cardiovascular system
S1 S2 heard ,no murmurs
PROVISIONAL DIAGNOSIS
Diabetic ketoacidosis due to missed insulin dose
Investigations
CUE
Sugars+
(Benedicts )
urine ketone bodies
Positive ( Rothera test )
USG abdomen
was normal
Management
IV FLUIDS
Normal saline
INJ HAI
GRBS CHARTING
Comments
Post a Comment