1801006097 short 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.

Presenting complaints:

A  45 years old male,resident of kodakonla mandal,janagam district hotel server by occupation came with  chief complaints of abdominal distension and shortness of breath and swelling of both lower limbs since 1 week.

HOPI: patient was apparently alright 7 days back then he developed swelling in the both limbs which was insidious in onset , gradually progressive,it was pitting in nature, no aggravating and relieving factors 

He developed shortness of breath which was  insidious in onset , gradually progressive , initially grade 2 but now progressed to grade 3 ,aggravated on walking relieved on taking rest .

Patient was alright 6  years ago and then he developed a minor injury to neck which was not healing and then went for regular checkup and was diagnosed as having diabetes and started on OHA, and 3 years ago he was diagnosed to be having hypertension and started on Tab. Telmisartan 40mg/OD,and was asymptomatic 7 months ago and then in the evening he suddenly became ,unresponsive and irrelevant talk and was taken to hospital and was found to be having hypoglycaemia and was asked to stop OHA,and was found to be having jaundice at that time and was asked to avoid alcohol but he didn’t stopped alcohol consumption.

And 5 months ago,he developed similar complaints and was admitted here and was diagnosed to be having,Acute decomponsated liver disease and was kept on conservative management, a diagnostic and therapeutic tap was done,showing 200cells,lymphocytic predominant cells and High saag and low protein profile and therapeutic Paracentesis was done 1L on day 1

1.75L on day 2 and 1.5L on day 3 and his complaints resolved and was discharged in a hemodynamically stable state,and was normal till 15 days and started developing pedal edema ,abdominal distension and SOB again and came here for further management.

Decreased Apetite and sleep since 2 days.

Chronic alcoholic since 20 years and last binge,30days ago.

Chronic smoker since 30years

Past history:

K/c/o CLD Since 5 months

K/c/o HTN since 2 years

K/c/o DM II since 6 years

Personal history:

Chronic alcoholic consumes 3 quarters/day 

Chronic smoker 40 cigarettes/day (since 30 years)

GENERAL PHYSICAL EXAMINATION:

At admission 

Patient is drowsy but arousable,

Icterus : present

Clubbing: present

Edema : present ( pedal edema) 

No signs of cyanosis, generalised lymphadenopathy

Vitals: 

Bp 140/80mmHg

PR 98bpm

RR 18cpm

Temp Afebrile 

Spo2 98% on RA

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

S1 AND S2 HEARD. 

NO MURMURS

RESPIRATORY SYSTEM: 

Bilateral air entry PRESENT. 

NVBS  HEARD

CENTRAL NERVOUS SYSTEM:

Patient is drowsy and arousable

Speech normal

No signs of meningeal irritation

P/A: 

Inspection: 

Abdomen is distended  , flanks are full 

 umbilicus everted,

Dilated veins present over the lower aspect of abdomen

No visible scars and sinuses 

Palpation: 

no local rise of temperature 

No tenderness

Fluid thrill absent 

Abdominal girth 124cms 

Percussion: 

Shifting dullness present 

Auscultation: 

bowel sounds not heard

Genital examination: scrotal edema was present 

Provisional diagnosis: 

Ascites  

Therapeutic paracentesis done on 28/02/2023 of 2 litres

INVESTIGATIONS:

ULTRASOUND:

IMPRESSION:

1. Heteroechoeic echotexture with surface irregularity of liver , correlate with LFT

2. gross ascites

3. PV shows to and fro flow

4. B/l raised echogenecity of kidneys

ECG: 

Chest x ray: 

Apraxia charting: 

APTT: 35 SEC

BLEEDING TIME: 2MIN 30 SEC

CLOTTING TIME: 5 MIN

BLOOD GROUPING: O POSITIVE

BLOOD UREA: 36 mg/dl

SERUM CREATININE: 1.2 mg/dl

PROTHROMBIN TIME: 18 sec

INR: 1.33

HCV: NEGATIVE

HBSAG: NEGATIVE

HIV : NEGATIVE

FBS: 103 mg/dl

SAAG:

SERUM ALBUMIN: 2.2 gm/dl

ASCITIC ALBUMIN: 0.3 gm/dl

SAAG: 1.9

ASCITIC FLUID PROTEIN : 0.8 g/dl

ASCITIC FLUID SUGAR: 151 mg/dl

ASCITIC FLUID AMYLASE: 40.6 IU/L

ASCITIC FLUID LDH: 56.6 IU/L

ASCITIC FLUID ADA: 24 U/L

2D ECHOCARDIOGRAPHY:

No RWMA, MILD LVH (+) (1.2cms) 

MODERATE TR+; PAH TRIVIAL AR+; NO MR

SCLEROTIC AV, NO AS/MS

EF: 62.   RVSP= 42+10= 52 MM HG

GOOD LV SYSTOLIC FUNCTION

NO DIASTOLIC DYSFUNCTION

MINIMAL PE(+)

IVC SIZE (1.25CMS) COLLAPSING

MILD DILATED R.A/R.V

Blood urea: 16 mg/dl

Serum creatinine: 1.1 mg/dl

Serum Na+  137 mEq/L

Serum K+  4.0 mEq/L

Serum Cl- 105 mmol/L

Serum Ca+2     1.05 mmol

Diagnosis:

ACUTE DECOMPENSATED ALCOHOLIC LIVER DISEASE

WITH ASCITIS (MODERATE)

WITH GRADE I HEPATIC ENCEPHALOPATHY

WITH ANEMIA(MACROCYTIC)

WITH K/C/O DM 6 YEARS AND HTN 3 YEARS

TREATMENT:

1. INJ. LASIX 60 mg IV/BD

2. INJ. CEFTRIAXONE 2 GM IV/BD

3. INJ. VITAMIN K 10 mg IV/OD

4. FLUID RESTRICTION  less than 1.5 litres/day

5. SALT RESTRICTION less than 2 gm/day

6. INJ. PAN 40 mg IV/PD

7. TAB. ALDACTONE 50mg PO/OD

8. TAB. TELMISARTAN 40 mg PO/OD

9. TAB. RIFAGUT 550 mg PO/BD

10. TAB. UDILIV 300 mg PO/OD

11. SYRUP. HEPAMERZ 15 ml PO/TID

12. O2 inhalation

13. Vitals monitoring

14. Abdominal girth monitoring

15. Grbs monitoring 

16. SYRUP. LACTULOSE 30 ml PO/TID