1801006039 - 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.
A 42 year old male from Nalgonda district, a Government employee by occupation came to our OPD with
C/o Abdominal distention since 7 days
Bilateral Pedal Edema since 3 days
History of Presenting illness
Patient was apparently asymptomatic 10 days ago then he developed Abdominal discomfort which increased on taking food
Patient developed gradual Abdominal Distention 1 week back which was associated with Shortness of breath even on sitting and while talking
Patient has complaints of burning sensation of legs and hands for the past one week for which he visited a Neurosurgeon at Nalgonda and was prescribed Gabapentin on the provisonal duagnosis of Sensory Axonal Neuropathy. Patient achieves short term relief with the medication.
3 days back patient noticed bilateral mild pedal edema on his way to office which increased by the end of the day and still persists.
Past History
Patient had H/o Jaundice 2 years back which was diagnosed on admission for Dengue hemorrhagic fever and was unconscious for about 3 days.
Not a k/c/o Diabetes mellitus, Hypertension, TB, Epilepsy, Asthma, CAD.
Personal history
Diet is mixed
Appetite is decreased
Sleep - Inadequate for the past 10 days but improved after taking Gabapentin for burning sensation of legs and hands
Bladder movements - Decreased urinary flow, dark coloured, foul smelling urine with burning sensation post micturition for the past 10 days.
Bowel movements every 2 days
Addictions - Chronic Alcoholic for the past 6 years and consumes more than 180ml whiskey every day.
No habit of Cigarette smoking.
History of weight loss in the past 2 years of about 20 kgs (70kgs to 50 kgs)
Family history- No similar complaints in the family
Drug History - On Gabapentin for the past 5 days
Surgical history - Underwent Appendicectomy surgery 17 years back
Daily Routine
Patient usually wakes up at 5am everyday and goes to work around 9am skips breakfast and has lunch around 4pm. He suffers with hunger pain in the epigastrium during early afternoon which radiates to the back and chest. Drinks alcohol at night and skips meals most of the times and sleeps around 11pm.
General Physical Examination
Patient was Conscious, Coherent and Cooperative.
Well oriented to time, place and person.
Undernourished and under built.
Pallor present
No Icterus, Cyanosis, Clubbing, Koilonychia, Generalised Lymphadenopathy
Bilateral Pedal edema present of Grade 2.
Vitals
Temperature - Afebrile
Pulse - 90 bpm
Respiratory rate - 22 cpm
Blood pressure - 120/80 mmHg
Systemic examination
CVS - S1,S2 heard
RS - BAE +
CNS - No focal neurological deficits
Abdomen
On Inspection
Abdomen is distended
Flanks are full
Umbilicus is central and inverted
Skin is stretched with Dilated veins on sides of the Abdomen
Appendicectomy scar present
On Palpation
Soft
Mild tenderness over Right Hypochondriac region
Liver not palpable
Spleen not palpable
On Percussion
Shifting dullness present
Liver span was difficult to percuss due to distended abdomen.
Provisional Diagnosis
Ascites secondary to Chronic Liver Disease
Investigations
Hemogram
RBS, HbA1c
CUE
LFT
serum Creatinine
Urea
Serum electrolytes
ECG
USG Abdomen
APTT
BT, CT
Ascitic tap
Fluid restriction to <1 L/day
Salt restriction to <2 gm/day
Inj. LASIX 40mg IV BD
Syrup Lactulose 30ml PO
BP/ PULSE/ RR/ TEMP Charting 4th hourly.
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