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Hall ticket number : 1701006042
Name :E.RishithaReddy
I've been given this case to for my final practical examination to show my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment plan.CASE PRESENTATION :
HISTORY :
A 50 year old male patient who is a farmer and a daily wage worker by occupation, a resident of Pochampally, came to the general medicine department on 02-06-2022 with
CHIEF COMPLAINTS :
1. Abdominal distension since 4 days
2. Pain abdomen since 3 days
3. Pedal edema since 3 days
HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic 6 months back, then he developed jaundice for which he was treated by a local private practitioner.
15 days back, he developed abdominal distension which was insidious in onset, gradually progressive which aggravated since 4 days and progressed to present size. There were no aggravating or relieving factors.
Patient had pain abdomen which was insidious in onset, gradually progressive since 3 days in the epigastric and right hypochondriac region and had no aggravating or relieving factors.
Patient complained of pedal edema of grade 2 since 3 days which was insidious in onset, gradually progressive and had no aggravating or relieving factors.
Associated symptoms : shortness of breath since 3 days.
No history of nausea and vomiting.
No history of chest pain, exercise intolerance.
No history of loss of weight, loss of appetite.
No history of evening rise of temperature, cough, night sweats.
No history of hematemesis, dilated veins, hemorrhoids, melena.
No history of facial puffiness, generalized edema.
No history of right upper quadrant pain.
DAILY ROUTINE :
Patient usually wakes up at 5:00 am and goes to field and comes home at 9am at 1:00 he will have his lunch .Then goes to work from 2pm to 6 pm and at 6:00pm he comes to home at 8:00pm he will have his dinner and at 9:30 pm he goes to sleep
PAST HISTORY :
No history of similar complaints in the past.
Patient is not a known case of Diabetes mellitus, Hypertension, Tuberculosis, Asthma, Epilepsy, Thyroid disease.
There is no history of blood transfusion or hospital admission.
PERSONAL HISTORY :
Diet : Mixed
Appetite : Decreased
Sleep : Adequate
Bowel and bladder movements : Urine frequency is reduced since 2 days and patient has an history of constipation.
Addictions : Patient is a chronic smoker and smoked 4-5 bidis per day since past 30 years (Pack years=Number of cigarettes x years of smoking/20; Number of bidis = Number of cigarettes/4; Therefore, Number of Pack years=5/4 x 30/20 = 1.88)
Patient consumes alcohol occasionally (whenever he gets tired from work) - 90 ml of whiskey (previously he was a chronic alcoholic but stopped consuming regularly 6 months back)
Patient consumes toddy occasionally
FAMILY HISTORY :
No significant family history.
HISTORY OF ALLERGIES :
No known food or drug allergies.
GENERAL PHYSICAL EXAMINATION :
Patient is conscious, coherent, co-operative and well-oriented to time, place and person.
Patient is moderately built and is moderately nourished.
There is pedal edema of grade 2.
Icterus is present.
There is no pallor, cyanosis, clubbing, lymphadenopathy.
Vitals :
Temperature : Afebrile
Pulse rate : 90 bpm, regular, normal volume.
Respiratory rate : 22 cpm
Blood pressure : 130/90 mm Hg Right arm in sitting position
GRBS : 90 mg/dl
O2 saturation : 98%
SYSTEMIC EXAMINATION :
Per abdomen :
On Inspection :
Abdomen appears to be distended and the umbilicus is everted.
Skin is smooth and shiny.
There are no abnormal swellings, discoloration, scars, sinuses, fistulae, venous dilatations.
On palpation :
There is no local rise of temperature.
Tenderness is present in the epigastrium.
No hepatomegaly. No splenomegaly.
Guarding is present.
Rigidity is absent.
Kidney not palpable.
On Percussion :
Tympanic note is heard on the midline of abdomen and a dull note is heard on the flanks in supine position.
Shifting dullness -Positive
Liver span could not be detected.
No renal angle tenderness.
Auscultation :
Bowel sounds are decreased.
No bruits could be heard.
Cardiovascular System : S1, S2 heard
Respiratory System : Normal vesicular breath sounds heard
Central Nervous System : Conscious; Speech normal ; Motor and sensory system examination is normal, Gait is normal.
INVESTIGATIONS :
1. Hemogram :
Hemoglobin : 9.8 g/dl
TLC : 7,200
Neutrophils : 49%
Lymphocytes : 40%
Eosinophils : 1%
Basophils : 0%
PCV : 27.4%
MCV : 92.3 fl
MCH : 33 pg
MCHC : 35.8%
RDW-CV : 17.6%
RDW-SD : 57.8 fl
RBC count : 2.97 millions/mm3
Platelet count : 1.5 lakhs/mm3
Smear : Normocytic normochromic anemia
2. Serology :
HbsAg : Negative
HIV : Negative
3. ESR :
15mm/1st hour
4. Prothrombin time : 16 sec
5. APTT : 32 sec
6. Serum electrolytes :
Sodium : 133 mEq/L
Potassium : 3 mEq/L
Chloride : 94 mEq/L
7. Blood Urea : 12 mg/dl
8. Serum Creatinine : 0.8 mg/dl
9. LFTs :
Total Bilirubin : 2.22 mg/dl
Direct Bilirubin : 1.13 mg/dl
AST : 147 IU/L
ALT : 48 IU/L
ALP : 204 IU/L
Total proteins : 6.3 g/dl
Serum albumin : 3 g/dl
A/G ratio : 0.9
10. Ascitic fluid :
Protein : 0.6 g/dl
Albumin : 0.34 g/dl
Sugar : 95 mg/dl
LDH : 29.3 IU/L
SAAG : 2.66 g/dl
11. Ascitic Fluid Cytology :
12. Ascitic fluid culture and sensitivity report :
13. Ultrasound :
Coarse echotexture and irregular surface of liver - Chronic liver disease
Gross ascites
Gallbladder sludge
14. ECG
15. X-ray
PROVISIONAL DIAGNOSIS :
Decompensated Chronic liver disease with ascites most likely etiology is alcohol.
TREATMENT :
Drugs :
1. Inj. Pantoprazole 40 mg IV OD
2. Inj. Lasix 40 my IV BD
3. Inj. Thiamine 1 Amp in 100 ml IV TID
4. Tab. Spironolactone 50 mg BB
5. Syrup Lactulose 15 ml HS
6. Syrup Potchlor 10ml PO TID
7. Fluid restriction less than 1L/day
8. Salt restriction less than 2g/day
Ascitic fluid tapping :
Ascitic fluid was tapped twice (2-06-2022 and 6-06-2022)
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