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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.
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short case
CHIEF COMPLAINTS:
A 77 yr old male resident of nalgonda came to opd with chief complaints of cough since 20 days , fever since 10 days , breathlessness since 5 days , altered sensorium since 2 days .
HISTORY OF PRESENTING ILLNESS :
patient had a CVA 7 yrs back , he had left hemiplegia and was bed ridden and he was on ryle’s tube for feeding .
Now patient presented with cough initially dry cough for 1 week now since 5 days he has productive cough with sputum which is yellow in color. Fever since 10 days which is high grade , intermittent and not associated with chills and rigor ,since 5 days he has continuous fever .Breathless ness since 5 days ,patient’s attender noticed this breatheless compared to his previous breathing pattern ,altered sensorium since 2 days. NO history of hemoptysis. NO history of nasal discharge , sore throat .
PAST HISTORY:
Patient had a cva 7 yrs back resulting left hemiplegia for which he underwent treatment.
He is a known case of diabetes since 2 years.
He is a known case of Hypertension since 10 years.
No History of asthma, thyroid, epilepsy, TB, congenital heart disease.
General Examination:
Patient is conscious, coherent, cooperative, with altered sensorium
Pallor - present
Icterus- absent
Cyanosis- absent
Clubbing- absent
No lymphadenopathy
No pedal edema
Vitals
Temperature- 101 F
Pulse- 110
BP- 140/80 mm Hg
SpO2- 95%
RR- 24 cpm
GRBS- 210 mg/dl
SYSTEMIC EXAMINATION
Respiratory System:
Inspection:
Shape and movement of the chest are normal
Trachea is central
Palpation
Trachea is midline
chest movements equal on
both sides
Apex beat - felt in the left 5th ICS
Increased vocal fremitus seen in right scapular, infra scapular axillary, infra axillar
Percussion
On percussion dullness noted in the right scapular, infra scapular axillary, infra axillary
other areas are resonant
Auscultation:
decreased breath sounds in the right scapular, infra scapular axillary, infra axillary
other areas- Normal vesicular breath sounds heard.
Fine crepitations heard
Increased vocal resonance
CNS
No focal neurological deficits.
Altered sensorium present.
Power Right Left
U/L 5/5 3/5
L/L 5/5 3/5
Tone Normal Increased
Reflexes
Babinski’s sign - left side positive
CVS
S1 S2 heard
No murmurs heard
GIT
Soft, non tender
No organomegaly
Normal bowel sounds heard
Investigations
Xray
Blood urea -30mg/dl
HBA1C-6.7%
HIV 1/2 RAPID TEST - NON REACTIVE
Anti HCV antibodies rapid - nonreactive
TOTAL BILIRUBIN -0.81mg/dl(normal-0 to 1mg/dl)
Direct bilirubin-0.17mg/dl(0 to 0.2mg /dl)
Serum creatinine -0.9 mg/dl (0.8 to 1.3 mg /dl)
Electrolytes -
Sodium 135meq/l
Potassium 3.5 meq/l
Chloride 98meq/l
Calcium -1.06 mmol/l
PROVISIONAL DIAGNOSIS
Right middle and lower lobe Pneumonia.
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