FINAL PRACTICAL-LONG CASE

MEDICINE CASE DISCUSSION

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I have been given this case, in an attempt to solve and understand the topic of "Patient's clinical data analysis”. This has helped me develop my competency in reading and comprehending clinical data including history taking, clinical findings and investigations. The goal is to come up with a diagnosis and treatment plan.  

HALL TICKET NO-1701006137

12TH JUNE 2022

FINAL PRACTICAL-LONG CASE

CHIEF COMPLAINS:

50 year old male, farmer by occupation, resident of Pochampally, came to Medicine OPD with complaints of : 

- Distended abdomen since 7 days 

- Pain abdomen since 7 days

- Pedal edema since 5 days 

- Breathlessness since 4 days.

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic 6 months ago when he developed jaundice and was treated at a private practitioner.

Later he developed abdominal distension about 7 days ago  which was insidious in onset, gradually progressive to the present size and is  associated with 

- Pain in epigastric and right hypochondric region which was also insidious in onset and gradually progressive,without any aggrevating or releiving factors

It was colicky type.

- Fever - high grade ,continuous , not associated with chills and rigor, decreased on medication, No night sweats.

- Not associated with Nausea, vomiting, loose stools 

He also complains of pedal edema which was insidious in onset ,gradually progressive ,bilateral pitting type,which is present below the knees {grade-2}

- Increases during the day - maximum at evening.

- No local rise of temperature and tenderness 

- Not relived on rest 

  

He also complained of shortness of breath since 4 days -  progressed to MMRC grade 4,it was insidious in onset,gradually progressive which aggrevated on eating and lying down,no relieving factors.

- No PND

- No cough/sputum/hemoptysis

- No chest pain

- No wheezing

Daily Routine : 

Wakes up at 5am and goes to field.

Comes home at 8am and has rice for breakfast. Returns to work at 9am.

1pm - lunch

2-6 pm - work

6pm - home

8pm - dinner

Alcohol- 2 times a week, 180 ml.

PAST HISTORY: 

No history of similar complaints in the past 

Medical history- not a known case of DM, HTN, TB, Epilepsy, Asthma, CAD

No surgical history

PERSONAL HISTORY: 

Mixed diet

Reduced appetite since 7 days

Sleep is disturbed due to breathlessness

Bowel movements are regular

 Bladder - oliguria since 2 days, no burning micturition, no feeling of incomplete voiding. 

No known Allergies

 Addictions - Beedi - 8-10/day since 20 years ; 

                     - Alcohol - Toddy - 1 bottle, 2 times a week, since 20 years;

                                     - Whiskey-180 ml, 2 times a week, since 5 years.

                                     - Last alcohol intake - 29th May, 2022 , amount : more than usual.

FAMILY HISTORY:

No similar complains in the family 

GENERAL EXAMINATION: 

Examined in a well lit room with proper consent 

Patient is conscious, coherent and co-operative.

Moderately built and nourished

Icterus - present (sclera)

Pedal edema - present - bilateral pitting type, grade 2

No pallor, cyanosis, clubbing, lymphadenopathy.

 

Vitals : 

Temperature- afebrile

Respiratory rate - 14 cpm

Pulse rate - 98 bpm

BP - 120/80 mm Hg.

TREMORS are seen on general examination

SYSTEMIC EXAMINATION: 

CVS : S1 S2 heard, no murmurs

Respiratory system : normal vesicular breath sounds heard.

Abdominal examination: 

INSPECTION : 

Shape of abdomen- distended

flanks -full

Umblicus - everted and central.no herniations present

Movements of abdominal wall - moves with respiration 

Skin is smooth and shiny;

No scars, sinuses, distended veins, striae.

PALPATION : 

Local rise of temperature is present .

Tenderness  is present in the epigastric region.

 No Hepatomegaly and splenomegaly 

Guarding present(volunatary contraction of abdominal wall musculature to avoid pain)

Rigidity absent(involuntary tightening of abdominal muscles)

No visible peristalsis  

Fluid thrill positive 

Liver not palpable 

Spleen not palpable 

Kidneys not palpable 

Lymph nodes not palpable 

PERCUSSION: 

Liver span : not detectable 

Fluid thrill: felt 

AUSCULTATION: 

Bowel sounds: heard in the right iliac region 

No bruit present

CNS EXAMINATION: 

Conscious 

Speech normal

No signs of meningeal irritation 

Cranial nerves: normal

Sensory system: normal

Motor system: normal

Reflexes:      Right.           Left. 

Biceps.         ++.                 ++

Triceps.         ++.                 ++

Supinator      ++.                  ++

Knee.              ++.                 ++

Ankle              ++.                  ++

Gait: normal 

INVESTIGATIONS: 

 

- Hemogram :

Hemoglobin : 9.8 g/dl

TLC : 7,200

Neutrophils : 49%

Lymphocytes : 40%

Eosinophils : 1% 

Basophils : 0%

PCV : 27.4%(40-50)

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

- LFTs :

Total Bilirubin : 2.22 mg/dl (0-1)

Direct Bilirubin : 1.13 mg/dl(0-0.2)

AST : 147 IU/L(0-35)

ALT : 48 IU/L(0-45)

ALP : 204 IU/L(53-128)

Total proteins : 6.3 g/dl(6.4-8.3)

Serum albumin : 3 g/dl(3.5-5.2)

A/G ratio : 0.9

- ESR :

15mm/1st hour

- Prothrombin time : 16 sec

- APTT : 32 sec

- Serum electrolytes :reduced 

Sodium : 133 mEq/L(136-145)

Potassium : 3 mEq/L(3.5-5.1)

Chloride : 94 mEq/L(98-107)

- Blood Urea : 12 mg/dl

- Serum Creatinine : 0.8 mg/dl

- Ascitic fluid :

Protein : 0.6 g/dl(<2.5)

Albumin : 0.34 g/dl

Sugar : 95 mg/dl (60-100)

LDH : 29.3 IU/L (230-460)

SAAG : 2.66  (<1.1)

- Serology : 

HbsAg : Negative

HCV : Negative

HIV : Negative

chest xRay

 

ECG

 

USG Abdomen-Coarse echotexture and irregular surface of liver - Chronic liver disease

Ascitic fluid cytology

Culture And Sensitivity Report

Severity of liver disease:

CHILD-PUGH-TURCOTTE SCORING SYSTEM:

Parameter                                       points assigned

                                                     1                     2                      3

Ascites                                    absent            slight             moderate

Bilirubin(mg/dl)                      <2                   2-3                    >3

Albumin(g/dl)                         >3.5              2.8-3.5                 <2.8    

Prothrombin time                  <4                   4-6                     >6

Encephalopathy                    None           Grade 1-2        grade 3-4

Interpretation:

Total score:  5-6   well compensated disease

                       7-9    significant functional compromise

                       10-15   decompensated disease

In this patient,

  

Ascites - moderate(3)

Bilirubin- 2.22mg/dl (2)

Albumin - 3g/dl (2)

Prothrombin time- 16 seconds  (3)

Encephalopathy- none(1)

Total score: 11

Therefore this patient's liver condition is in Decompensated state.

PROVISIONAL DIAGNOSIS: 

This is a case of  Decompensated  Chronic liver failure with ascites which may be secondary to chronic alcohol consumption.

TREATMENT: 

Fluid restriction less than 1L per day     

Salt restriction less than 2 gm per day   

Inj. Pantoprazole 40 mg IV OD

Inj. Lasix 40 my IV BD

Tab. Spironolactone 50 mg BB

Inj. Thiamine 1 Amp in 100 ml IV TID

Syrup Potchlor 10ml PO TID

Syp. Lactose 15ml TID 

Ascitic fluid tapping was done.