PATIENT CAME WITH C/O DISTENSION OF ABDOMEN, SHORTNESS OF BREATH, PEDAL EDEMA

 Case History and Clinical Findings

PATIENT CAME WITH C/O DISTENSION OF ABDOMEN SINCE 3 MONTHS

C/O SHORTNESS OF BREATH SINCE 3 MONTHS

C/O PEDAL EDEMA SINCE 20 DAYS

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 3MONTHS BACK THEN DEVELOPED DISTENSION OF ABDOMEN WITH SHORTNESS OF BREATH , GRADE II , INSIDIOUS IN ONSET , GRADUALLY PROGRESSIVE , NO AGGREVATING AND RELIEVING FACTORS .

C/O PEDAL EDEMA SINCE 20 DAYS, B/L PITTING TYPE , EXTENDING UPTO THE KNEE

C/O DECREASED IN URINE OUTPUT SINCE 20 DAYS

C/O FEVER SINCE 5 DAYS ON AND OFF, ASSOCIATED WITH CHILLS AND RIGORSNO C/O ORTHOPNEA ,PND , CHEST PAIN

NO C/O ORTHOPNEA , PND, CHESTPAIN ,PALPITATIONS

NO C/O PAIN ABDOMEN , VOMITINGS ,LOOSE STOOLS

PAST HISTORY:
K/C/O CLD
K/C/O T2DM SINCE 6 MONTHS AND IS ON UNKNOWN MEDICATION
H/O ALBUMIN TRASFUSION DONE
N/K/C/O HTN, EPILEPSY, ASTHMA, THYROID DISORDERS

PERSONAL HISTORY :
DIET :MIXED
APPETITE :DECREASED
SLEEP: DISTURBED
H/O ALCOHOL INTAKE SINCE 20 YEARS EVERY DAY ABOUT -50ML
NO H/O TOBACCO INTAKE
NO H/O ALLERGIES

FAMILY HISTORY :
N/K/C/O DM, HTN ,EPILEPSY, ASTHMA , THYROID DISODERS .
GENERAL EXAMINATION :
PATIENT IS CONCIOUS, COHERENT AND COOPERATIVE , WELL ORIENTED TO TIME , PLACE AND PERSON
PALLOR : +
EDEMA PRESENT EXTENDING UPTILL THE KNEE
NO ICTERUS , CYANOSIS, CLUBBING , LYMPHADENOPATHY

VITALS :
TEMPERATURE :98.2F
BP: 120/80 MM/HG
PR: 84 BPM
SPO2: 99%
GRBS : 198 MG%
RR: 16CPM
SYSTEMIC EXAMINATION :
CVS: S1, S2 + , NO MURMURS
RS:BAE+,NO ADDED SOUNDS
CNS: NAD
PER ABDOMEN :
INSPECTION :
ABDOMEN - DISTENDED

UMBILICUS - CENTRAL
SCARS +,SINUSES

PALPATION :
TENDERNESS IN THE PERIUMBILICAL REGION
NO HEPATOMEGALY
NO SPLEENOMEGALY
HERNIAL ORIFICE - NORMAL
FREE FLUID - YES

PERCUSSION :
DULL NOTE ALL OVER THE ABDOMEN

AUSCULTATION :
BOWEL SOUNDS+

COURSE IN HOSPITAL:
PATIENT IS ADMITED I/V/O C/O DISTENSION OF ABDOMEN SINCE 3 MONTHS ,C/O SHORTNESS OF BREATH SINCE 3 MONTHS
AND C/O PEDAL EDEMA SINCE 20 DAYS AND WAS DIAGNOSED TO HAVE DECOMPENSATED CHRONIC LIVER DISEASE WITH GROSS ASCITIS WITH B/L PLEURAL EFFUSION ( MODERATE ) WITH K/C/O TYPE 2 DM SINCE 5 MONTHS .
PATIENT VITALS AT TIME OF ADMISSION :
TEMPERATURE :98.2F
BP: 120/80 MM/HG
PR: 84 BPM
SPO2: 99%
GRBS : 198 MG%
RR: 16CPM
BOTH DIAGNOSTIC AND THERAPEUTIC PARACENTESIS HAS BEEN DONE ON 28/7/23 AND 1L OF ASCITIC FLUID IS BEING REMOVED . AND ON ASCITIC FLUID ANALYSIS - HIGH SAAG ,LOW PROTEIN WAS FOUND .
PSYCHIATRY REFERRAL IS BEING KEPT ON 29/7/23 I/V/O ALCOHOL DEPENDANCE SYNDROME AND ADVISED - TAB. BACLOFEN XL 20MG PO OD AND CONTINUE THIAMINE SUPPLEMENTATION .
DIAGNOSTIC PLEURAL TAP BEING DONE ON 29/7/23 AND THERAPEUTIC PLEURAL TAP DONE ON 31/7/23 - 700ML OF PLEURAL FLUID BEING REMOVED .
GASTRO REFEERAL WAS TAKEN ON 1/8/23 AND ADVISED LARG3 VOLUME PARACENTESIS WITH ALBUMIN INFUSION .
ASCITIC TAP DONE ON 2/8/23 AROUND 1.8 L ASCITIC FLUID IS BEING REMOVED .
PATIENT IS BEING TREATED CONSERVATIVELY AND DISCHARGED IN HEAMODYNAMICALLY STABLE CONDITION .

VITALS :
TEMPERATURE-97F
BP- 110/70 MMHG
PR-88 BPM
RR-16 CPM

Provisional Diagnosis:-
DECOMPENSATED CHRONIC LIVER DISEASE WITH GROSS ASCITIS WITH B/L PLEURAL EFFUSION ( MODERATE , TRANSUDATIVE ) , ANEMIA OF CHRONIC DISEASE WITH K/C/O TYPE 2 DM SINCE 5 MONTHS

Investigation:-

HEMOGRAM :
Hb - 7.7
PCV- 22.3
TLC - 5,000
RBC COUNT - 2.36
PLATELET COUNT - 98,000
RBS - 194 MG/DL
BLOOOD UREA - 14
S. CREATININE - 0.7
S. NA + : 126
S. K+ :3.3
S.CL : 97

LFT:
T. BILIRUBIN - 1.75
D.BILIRUBIN -0.41
SGPT -11
SGOT- 27
ALKALINE PHOSPHATE : 161
T. PROTEINS - 5.7
ALBUMIN : 3.8

CUE :
COLOUR -PALE YELLOW
RBC - NIL
PUS CELL S- 3-4
SEROLOGY - NEGATIVE

04/08/23
HEMOGRAM :
Hb - 7.3
PCV- 21.2
TLC - 7500
RBC COUNT - 2.20
PLATELET COUNT - 1,30,000
SERUM ELECROLYTES
S. NA + : 132
S. K+ : 4.2
S.CL : 91

LFT:
T. BILIRUBIN - 1.95
D.BILIRUBIN -0.65
SGPT -11
SGOT- 30
ALKALINE PHOSPHATE : 172
T. PROTEINS - 5.6
ALBUMIN : 2.49
ASCITIC FLUID ANALYSIS :
ASCITIC FLUID SUGAR- 215 MG/DL
ASCITIC FLUID PROTEIN - 1.7 G/DL
SAAG- 2.96
ASCITIC FLUID LDH - 87.6 IU/L
ASCITIC FLUID AMYLASE - 3.7 IU/L
PLEURAL FLUID ANALYSIS:
PLEURAL FLUID ADA - 21U/L
PLEURAL FLUID SUGAR- 187 MG/DL
PLEURAL FLUID PROTEIN - 1.6 G/DL
PLEURAL FLUID LDH- 156
UGIE - SHOWN DIALATED ESOPHAGEAL VEINS

Treatment Given:-
1. FLUID RESTRICTION <2L/DAY
2. SALT RESTRICTION <2 GM /DAY
3.INJ. OPTINEURON 1 AMPULE IN 100ML NS IV OD AT 2PM
4. INJ. THIAMINE 200MG IN 100 ML NS IV OD AT 2PM
5. INJ. LASIX 40MG IV /BD ( IF SBP> 110MG)
6. INJ. HAI SC/ TID PREMEAL
7. TAB. BACLOFEN - XL 20MG
8. TAB. SPIRONOLACTONE 25MG PO/BD
9. TAB. UDILIV 300MG PO BD
10. TAB. RIFAGUT 55OMG PO/BD
11.SYP. LACTULOSE 100ML PO/BD
12. SYP. HEPAMERZ 10ML PO/BD
13.PROTEIN POWDER 2 TBSP IN 1 GLASS OF WATER PO TID
14. 2 EGG WHITES / DAY
15. GRBS 7 PROFILE MONITORING
16. STRICT I/O CHARTING
17. MONITOR VITALS BP/PR/RR/TEMPERATURE HOURLY
18.ABDOMINAL GIRTH AND WEIGHT MEASUREMENT

Comments

Post a Comment

Popular posts from this blog

14 yr old female with shortness of breath

Image
 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. This is a case of a 14 year old girl who came with chief complaints of: Shortness of breath since 2 days Fever since 1 day Abdominal pain since 1 day Vomiting 1 episode HOPI:  The patient was apparently asympt
Read more

PATIENT WITH C/O SOB SINCE 7 DAYS

PATIENT WITH C/O SOB SINCE 7 DAYS  PATIENT WAS APPARENTLY ASYMPTOMATIC 7 DAYS AGO THEN HE DEVELOPED SOB OF INSIDIOUS ONSET GRADUALLY PROGRESSIVE AND AGGRAVATED SINCE PAST 2 DAYS COUGH + WITH EXPECTORATION,BLOOD TINGED + FEVER + SINCE 7 DAYS ,LOW GRADE NOT WITH CHILLS AND RIGOR,COLDSORE THROAT -, ABDOMINAL PAIN -,VOMITING -,LOOSE STOOLS - N/KC/O CVA,CAD,TB,EPILEPSY K/C/O TB SINCE 7 YEARS AGO USED MEDICATION K/C/O HTN AND DM II SINCE 2 YEARS ON MEDICATION PERSONAL HISTORY APETITE-DECREASED SLEEP-ADEQUATE BOWEL AND BLADDER- REGULAR NO ALLERGIES  GENERAL EXAMINATION; PATIENT IS CONSIOUS ,COHERENT,COOPERATIVE  NO SIGNS OF PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,EDEMA  VTALS PR-108 BPM BP- 120/60 MMHG RR-22 CPM  TEMP AFEBRILE SYSTEMIC EXAMINATION :  CVS : S1 S2 HEARD , NO MURMURS  RS : BAE +,RHONCI ?  PER ABDOMEN : SOFT , NON TENDER , NO ORGANOMEGALY  CNS : HGHER MOTOR FUNCTIONS PRESENT , NO FND  PULMONOLOGY REFFERAL DONE I/V/O BLOOD TINGED SPUTUM AND PREVIOUS TB ADVISED TRUNAAT,HRC
Read more

PATIENT PRESENTED TO CASUALTY WITH C/O FEVER SINCE 1 WEEK, VOMITINGS SINCE 1 WEEK

 PATIENT PRESENTED TO CASUALTY WITH C/O FEVER SINCE 1 WEEK, VOMITINGS SINCE 1 WEEK( 4 EPISODES/DAY) NAUSEA PRESENT NON COMPLIANCE TO MEDICINE FOR 3 DAYS LAST WEEK AND FOR 3 DAYS THIS WEEK  HOPI: PATIENT WEAS APPARENTLY ASYMPTOMATIC 1 WEEK AGO THEN SHE DEVELOPED FEVER OF LOW GRADE WITH CHILLS AND RIGORS ,INTERMITTENT WITH VOMITINGS( 4 EPISODES PER DAY ) ,NON PROGRESSIVE ,NON BILIOUS ,CONTAIN FOOD PARTICLES AS CONTENT K/C/O DM2 SINCE 20 YEARS( USING METFORMIN 500 MG PO/OD) K/C/O HTN SINCE 20 YEARS( USING TELMIKIND 40 MG PO/OD ,NOT USING SINCE 3 DAYS)  ON EXAMINATION: PT IS C/C/C NO SIGNS OF PALLOR,ICTERUS,CLUBBING,CYANOSIS,LYMPHEDENOPATHY,PEDAL EDEMA VITALS: TEMP: 98.2  PR-100 BPM  BP: 140/80 MM HG  RR: 16 CPM  CVS: S1, S2+,NO MURMURS  RS: BAE +, PROVISIONAL Diagnosis  DIABETIC ACIDOSIS SECONDARY TO NON COMPLIANCE (RESOLVED) WITH AKI ON CKD SECONDARY TO LEFT HYDROURETRONEPHROSIS WITH HYPERKALEMIA(RESOLVED) WITH DILATED CARDIOMYOPATHY WITH HFMEF(EF 4%) WITH HYPONATREMIA (RESOLVED) WITH K/
Read more