A case of 50year old male

 Name: J. Akash

28/12/2022

Roll no. 53




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 a diagnosis and treatment plan.








Following is the view of my case :


Cheif complaints

A 50 year old male came with abdominal distension since 10 days

decreased apetite since 15days

Patient was apparently asymptomatic 10days back then he developed abdominal distension  after which he used herbal medication 

abdominal distension associated with pain


patient developed yellowish discoloration of eyes , investigated for the same and found to elevated bilirubin levels


significant weight loss 15kg,loss of appetite 

No h/o fever, headache,nausea , vomitings

No h/o loose stools, burning micturition

No h/o SOB, orthopnea,PND

No h/o chest pain, palpitations





PAST HISTORY:

Not a known case of DM/HTN/ASTHMA/EPILEPSY/CAD


PERSONAL HISTORY:

Diet -mixed 

apetite -decreased since 10days

bowel&bladder-regular

sleep- adequate 

addictions-Alcoholic since 15years (100ml/day)

No significant family history

GENERAL EXAMINATION:

Patient is conscious, coherent, co-operative well orientated to time ,place, person

No pallor, cyanosis,edema,lymphadenopathy

   icterus(+)

  





VITALS:  

bp-120/70mmhg

PR-84bpm

RR-18 cpm

Spo2-98%

CVS- S1 S2 heard

     No thrills and murmurs

RS- trachea central

      BAE+,NVBS

ABDOMEN:

  INSPECTION:

abdomen is distended 

 umblicus is central and everted

no visible pulasations,scars,sinuses

No visible peristalisis

No dilated veins

PALPATION:

No rendernesa,No palpable mass

shifting dullness present

fluid thrill absent

liver and spleen not palpable

PERCUSSION: dull note 

CNS-Pt is conscious,alert

No meaningeal signs


INVESTIGATIONS:

USG- Moderate Ascitis,Grade-2fatty liver



Upper GI endoscopy:


Chest XRAY:



investigation chart

  Ascitic fluid : sugars-48, proteins-5.1 , LDH-155, Alb-2.1   CBNAAT POSITIVE 

serum : Alb-2.6 SAAG-0.46




2D echo



TREATMENT:
  

on 23/12/2022
 1.Therapeutic / diagnostic Ascitic tap
2.Tab.lasix 40mg po/BD
3.syp.lactulose 20ml/po/HS
4.Inj.Thiamine /IV/OD


24/12/2022
Under strict aseptic conditions diagnostic ascitic tap was done and 20ml fluid aspirated


S: 
apetite decreased

O:
 Pt conscious/coherent/co-operative
 Bp-120/700mmhg
 PR-92bpm
 RR-16cpm
GRBS-117mg/dl
 Temp-Afebrile to touch
 CVS-S1 S2 +
 P/A: Distended,fluid thril-Ab, shifting dullness present
 RS: BAE+
 CNS:HMF intact

A:
Decompensated liver disease with Ascites under evaluation (Low SAG HIGH PROTEIN)


P:
1)Tab .lasix 40mg po/BD
2)syp.lactulose 20ml/po/HS
3)Inj.Thiamine 100mg in 100ml NS IV/BD
Monitor vitals
 

25/12/2022

S: 
stools passed 
apetite normal
no fever spikes
no headache & vomitings

O:
 Pt conscious/coherent/co-operative
 Bp-120/80mmhg
 PR-84bpm
 RR-18cpm
 Temp-Afebrile to touch
 CVS-S1 S2 +
 P/A: Distended,fluid thril-Ab, shifting dullness present
 RS: BAE+
 CNS:NAD

A:
Decompensated liver disease with Ascites under evaluation (Low SAG HIGH PROTEIN)


P:
1)Tab .lasix 40mg po/BD
2)syp.lactulose 20ml/po/HS
3)Inj.Thiamine 100mg in 100ml NS IV/BD
Monitor vitals
 


26/12/2022

S: 
stools passed 
apetite normal
no fever spikes
no headache & vomitings

O:
 Pt conscious/coherent/co-operative
 Bp-120/80mmhg
 PR-82bpm
 RR-15cpm
 Temp-Afebrile to touch
 CVS-S1 S2 +
 P/A: Soft .nontender
Distended,fluid thril-Ab, shifting dullness present
 RS: BAE+
 CNS:NAD

A:
Ascites under evaluation (Low SAG HIGH PROTEIN)
(? TB peritonitis)

P:
1)Tab .lasix 40mg po/BD
2)syp.lactulose 20ml/po/HS
3)Inj.Thiamine 100mg in 100ml NS IV/BD
Monitor vitals
 


27/12/2022

S: 
stools passed 
apetite normal
no fever spikes
no headache & vomitings

O:
 Pt conscious/coherent/co-operative
 Bp-120/70mmhg
 PR-78bpm
 RR-15cpm
 Temp-Afebrile to touch
 CVS-S1 S2 +
 P/A: Soft .nontender
Distended,fluid thril-Ab, shifting dullness present
 RS: BAE+
 CNS:HMF intact

A:
Ascites under evaluation (Low SAG HIGH PROTEIN)
(? TB peritonitis)

P:
1)Tab .lasix 40mg po/BD
2)Tab.hepamerz 500mg po/OD
3)Inj.Thiamine 100mg in 100ml NS IV/BD
4)Tab.udiliv 300mg po/BD
5)Tab.Rifagut 500mg po/BD
6)Inj.monocef 1gm IV/BD
 


28/12/2022

 S:
stools passed 
apetite normal
no fever spikes
no headache & vomitings
No abdominal pain

O:
 Pt conscious/coherent/co-operative
 Bp-110/60mmhg
 PR-63bpm
 RR-18cpm
 Temp-Afebrile to touch
 CVS-S1 S2 +
 P/A: Soft .nontender
Distended,fluid thril-Ab, shifting dullness present
 RS: BAE+
 CNS:HMF intact

A:
Ascites under evaluation (Low SAG HIGH PROTEIN)
(? TB peritonitis)
with lowgrade esophageal varices with bile reflux gastritis

P:
1)Tab .lasix 40mg po/BD
2)Tab.hepamerz 500mg po/OD
3)Inj.Thiamine 100mg in 100ml NS IV/BD
4)Tab.udiliv 300mg po/BD
5)Tab.Rifagut 500mg po/BD
6)Inj.monocef 1gm IV/BD
 7)syp.lactulose 25ml/po/HS









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