1801006119-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. 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.
A 30year male,who is a resident of chityala came with chief complaints of:
Yellowish discoloration of eyes since 3months
Swelling of both lower limbs since 1 week
Abdominal distension since 1 week
Fever since 2 days
HOPI:
Patient was apparently asymptomatic 3 months back and then developed yellowish discoloration of eyes,which is insidious in onset, gradually progressive
C/o bilateral swelling of both lower limbs since 1 week,which is insidious in onset, gradually progressed till knees
C/o abdominal distension, insidious in onset, gradually progressed to present size.
C/o fever since 2 days,high grade,not associated with chills,rigor,relieved on medication,no diurnal variation.
No h/o pruritus,pale colored stools,loose stools, vomitings, haematemesis,melena,loss of weight,chest pain, dyspnoea, palpitations, decreased urine output,altered bowel habits and no h/o blood transfusion, hepatitis exposure.
PAST HISTORY:
Similar complaints were noticed 1year ago-yellowish discoloration of eyes and subsided with in 1month and then he stopped consuming alcohol for 3months and later started drinking again.
N/k/c/o-DM,HTN,TB,Asthma,epilepsy,CVD,CAD.
PERSONAL HISTORY:
He takes mixed diet
Appetite decreased since 2 days
Sleep adequate
Bowel and bladder habits are regular
H/o alcohol consumption since 5yrs,drinks about 180ml per day
Drinks toddy occasionally.
FAMILY HISTORY:
No significant family history
GENERAL EXAMINATION:
Patient is conscious, coherent, cooperative, moderately built and nourished.
Icterus present
No signs of pallor,cyanosis,clubbing, lymphedenopathy, generalised edema.B/l pedal edema,pitting type,present upto knees.
Temperature:98f
Pulse rate:76bpm
Respiratory rate:18cpm
BP:110/70mm hg
SYSTEMIC EXAMINATION:
PER ABDOMEN EXAMINATION:
Ecchymosis at the site of puncture for amniotic fluid
INSPECTION:
Shape of abdomen: Distended
Flanks are full
Umbilicus:Inverted, vertically drawn down.
Skin:Shiny
All quadrants are moving equally with respiration
No visible peristalsis,hernial orifices intact
Visible superficial abdominal vein running vertically down
External genital-normal
Palpation:
No local rise of temperature and tenderness present-diffuse in all quadrants.
All inspectory findings are confirmed by palpation
No rebound tenderness,guarding rigidity
No hepatosplenomegaly
Percussion:
Shifting dullness present
No fluid thrill
Liver span -12cms
Auscultation:
Bowel sounds heard
No arterial bruit, venous hum.
RESPIRATORY SYSTEM:
-Upper respiratory tract:No DNS,Nasal polyp
Oral cavity:Good oral hygiene.No loss of tooth/caries.
Posterior pharyngeal wall-normal.
-Lower respiratory tract:
On inspection:
Shape of chest: Elliptical,b/l symmetrical chest.
Trachea appears to be central
Chest moves on respiration and equal on both sides.
No accessory respiratory muscles are used in respiration.
Apical impulse is not visible.
No scars, sinuses,engorged veins.
No kyphosis, scoliosis.
Palpation:
No local rise of temperature, tenderness.All inspectory findings are confirmed by palpation.
Trachea-central position
Apex beat-5th ICS medial to midclavicular line
Tactile vocal fremitus: decreased over infra scapular, inframammary areas bilaterally
Percussion:
On direct percussion resonant note is heard
Areas of percussion:
Supraclavicular
Infraclavicular
Mammary
Inframammary
Axillary
Infra axillary
Supra scapular
Infra scapular
Inter scapular
On indirect percussion: resonant note heard over all areas except over infra axillary and infra scapular.
Auscultation:
Bilateral air entry present.
Normal vesicular breathe sounds heard.
Decreased breathe sounds over b/l infra axillary and infra scapular areas
No added sounds like Crackles,wheeze.
Decreased vocal resonance over basal areas.
CVS EXAMINATION:
JVP- Not raised,normal wave pattern.
-on inspection:
shape of chest wall elliptical, no visible pulsations, no engorged veins present.
Apical impulse is not visible
Palpation:
Inspector findings confirmed by palpation
apex beat over left 5th intercostal space medial to midclavicular line.
No parasternal heaves
No precordial thrill
No dilated veins
Auscultation:
s1 and s2 heard no murmurs heard.
CNS EXAMINATION:
Higher mental functions:normal
Cranial nerves: Intact
Motor system:
Right Left
Bulk UL n n
LL n n
Tone UL n n
LL n n
Power UL 5/5 5/5
LL 5/5 5/5
Reflexes:
Superficial reflexes: present
Deep reflexes:Present
Gait normal
No involuntary movements
Sensory system:
Pain, temperature, pressure, vibration perceived
Cerebellar signs:
No nystagmus,Finger nose test positive,Heel knee test positive
No signs of meningeal irritation.
PROVISIONAL DIAGNOSIS:
Decompensated chronic liver disease secondary to alcohol
INVESTIGATIONS:
Inj.Cefotaxim 1gm,iv,bd later escalated to inj.Meropenem due to high grade fever
Syp Lactulose to pass 3-4 stools/day
Syp Potchlor 10ml,po,bd
Fluid and salt restriction
PROVISIONAL DIAGNOSIS:
Decompensated chronic liver disease secondary to alcohol.
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