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
Comments
Post a Comment