1801006192 LONG CASE

 This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .

 

I’ve 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 . 

A 72 year old gentleman, farmer by occupation came with 

CHIEF COMPLAINTS of-

Abdominal distension since 1 month

Decrease appetite since 1 week

Decreased urine output since 1 week

Swelling of right lower limb since 2 days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 2 months ago then he developed pain in the abdomen which was insidious in onset,  diffuse , intermittent non radiating. 

He then noticed abdominal distension since 1 week which was gradually progressive  increasing after food intake and no relieving factors

C/o decreased urination frequency i.e, 2-3 times a day

An ascitic fluid tap was done at KIMS which revealed high saag high protein with decreased sr. Amylase.

He was diagnosed with ascites secondary to decompensated liver disease, spontaneous bacterial peritonitis with Heart failure with preserved ejection fraction and acute kidney injury

Patient got treated and CT abdomen findings were suggestive of Hepatocellular carcinoma 

He was then referred to MNJ cancer hospital where liver biopsy was done which showed no malignancy & was asked for repeat biopsy .

Patient now again, presented with 

Abdominal distension which was progressive associated with shortness of breath since yesterday which aggravated on lying down relieved on sitting 

Decreased urine output 1-2 times a day, dark yellow in colour not associated with burning micturition, urgency, frequency, dribbling, strangury

H/o episode of vomiting, 2 days ago 1 episode, ,non projectile, non bilious , foul smelling , non blood stained, containing food particles

H/o pedal edema in right leg followed by left leg progressive and pitting type 

H/o constipation since 1 month 

H/o reduced appetite since one week

H/O weight loss present (5-6 kgs in past 2 months)

No H/O fever, nausea, vomitings, loss of consciousness, pruritis 

PAST HISTORY: 

H/o similar complaints 1 month ago

Not a known case of DM, HTN, CAD, Asthma, Tuberculosis, Epilepsy.

No h/o previous blood transfusions

No h/o previous abdominal surgeries

FAMILY HISTORY: 

Not significant 

PERSONAL HISTORY :

Diet : mixed

Appetite: decreased

Sleep : disturbed

Bowel and bladder:  deceased 

Addictions alcohoic - occasionally 

Non smoker

DRUG HISTORY -

Analgesic tablets and injections for pain in lower limbs since one year

ALLERGY HISTORY : no known allergies

GENERAL PHYSICAL EXAMINATION:

The patient is conscious, coherent, cooperative, well oriented to time, place and person. 

PR - 102bpm

BP - 130/80 mmhg

RR - 20 cpm

SpO2 - 98% on RA

GRBS - 106mg/dl

Pallor+

Icterus present

B/l Pedal edema present

Tongue appears beefy and atrophic

No cyanosis, clubbing, koilonychia, lymphadenopathy 

HEAD TO TOE EXAMINATION

Eyes - icterus  

Hair normal

Madarosis present

Oral cavity normal - no fetor hepaticus

No parotid enlargement 

Skin - normal ; no spider angiomata

Nails - normal 

No flapping tremors 

SYSTEMIC EXAMINATION:

I have taken consent of the patient before examining

I examined my patient in a well lit room in supine position.

PER ABDOMEN: 

INSPECTION:

Abdomen is uniformly distended 

Umbilicus central and not everted

Flanks appear full

No scars , sinuses, dilated veins, visible pulsations

Hernial orifices are normal

PALPATION:

No local rise of temperature 

No tenderness (local tenderness at the site of ascitic tap which was done yesterday)

Liver and spleen not palpable

No guarding and rigidity 

Shifting dullness present 

Fluid thrill absent 

Measurements

Abdominal girth (Upper segment) : 97 cm

Xiphisternum to umbilicus (lower segment) - 22 cms

Public symphysis to umbilicus - 12cms

Upper segment: lower segment ratio >1

PERCUSSION:

Liver borders-

upper border - 5 th intercostal space in mid clavicular line

lower border not appreciable

AUSCULTATION:

Bowel sounds were not clearly audible.

No bruit , venous hum or friction rub.

CARDIOVASCULAR SYSTEM EXAMINATION

Inspection - 

Chest Wall is Symmetrical

No precordial Bulge 

No dilated veins, scars, sinuses

Apical impulse - Not visible

Jugular Venous Pulse - Normal

Palpation - 

Apical Impulse - felt on left 5 th intercostal space lateral to the midclavicular line 

No thrills, no dilated veins

Auscultation - 

All four areas auscultated 

Mitral tricuspid aortic and pulmonary

S1 S2 heard; no murmurs 

RESPIRATORY SYSTEM

Upper Respiratory Tract: 

Nasal cavity - normal 

Nasopharynx - normal 

Oropharynx - normal

Larynx - normal

Lower Respiratory Tract:

INSPECTION:

Shape of chest: elliptical

Trachea: appears to be central

Chest appears to move bilaterally symmetrical movements with respiration

No usage of Accessory muscles 

Apical impulse Normal

No scars, sinuses

PALPATION:

All inspectory findings confirmed

Trachea: central

Tactile vocal fremitus: could not be assessed

Chest movements-could not be assessed

PERCUSSION:

Supra clavicular 

Infra clavicular

Mammary

Inframammary

Axillary

Infra axillary

Supra scapular

Infra scapular

Inter scapular

All areas examined .  All areas are resonant 

AUSCULTATION:

Normal vesicular breath sounds heard

No adventitious sounds heard

CENTRAL NERVOUS SYSTEM EXAMINATION

Higher Mental Functions are intact

Motor system - normal 

Tone normal in upper and lower limbs

Power 5/5 in right and left upper and lower limbs

Reflexes - 

Superficial reflexes intact

Deep tendon reflexes - 

2+ in right and left upper and lower limbs

Plantar reflex - flexion

Sensory system - normal 

No Gait Abnormalities

No meningeal signs present

EXTERNAL GENITALIA-

No testicular atrophy

No scrotal edema

INVESTIGATIONS-

Complete Blood Picture - 

HB - 8.6 g%

TLC - 19,400 

PLT -  1.6 LAKH

RBC count  2.8 lac

PCV  26

Normocytic normochromic anemia with neutrophilic leucocytosis

Renal Function Test-

Sr creatinine- 3.6 mg/dl (increased)

Electrolytes- 

Na 125

K 3.9

Cl 96

Ca 0.98

Blood urea: 155 mg/dl

Complete Urine Examination

Normal

Liver Function Test - 

Total bilirubin -  11.58mg/ dl

Direct bilirubin - 9.45mg/dl

SGOT - 597 IU/L

SGPT -  117IU/L

ALP -  628IU/L

Total protein -  5.6gm/dl

Albumin - 2.23g/dl

A/G ratio 0.66

Serology- 

HbsAg negative

Ultrasound- 

Irregular and nodular border of the liver with altered echotexture

Hepatomegaly

Gross ascites 

Chest X ray

Ascitic fluid analysis- 

Ascitic fluid tap was done yesterday night with due consent of the patient 

Results-

LDH - 153 IU/L - decreased

Protein - 1.4 g/dl

Sugar- 73 mg/dl

Protein sugar within normal limits

Ascitic albumin - 0.67 g/dl

SAAG - high

Ascitic fluid Amylase- 31.7IU/L

Total count - 550 cells

Differential count 

Neutrophils- 98%

Lymphocytes- 2%

PROVISIONAL DIAGNOSIS- 

ASCITES SECONDARY TO DECOMPENSATED LIVER DISEASE

HEART FAILURE WITH PRESERVED EJECTION FRACTION (EF - 58%)

TREATMENT :

1. IV fluids NS at 30 ml/hr 

2. Inj. Lasix 40mg iv/bd 

3. Fluid restriction <2L/day

4.  Salt restriction <1.2g/ day

5. Syrup lactulose 30ml PO/BD

6. Inj.optineuron 1 ampule in 100ml NS iv/od

7. Inj. Cefotaxime 2gm Iv/tid

8. BP ,PR monitoring every 4 th hourly

9. Abdominal girth and weight monitoring.