This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
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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
The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted.
CONSENT WAS TAKEN FROM BOTH PATIENT AND ATTENDERS
Chief complaints :
A 50 year old male came with complaints of
-Abdominal distension since 10 days
-Bilateral lower limb swelling since 8 days
HISTORY OF PRESENTING ILLNESS:
-Patient was apparently asymptomatic 10 days back then he had abdominal distension which was insidious in onset, gradually progressive not associated with pain ,no relieving and aggregating factors.
- He has associated bilateral pedal edema since 8 days ,which is pitting type extending from ankle to knee, more in the evening hours, gradually progressive.
-No history of fever
-No H/o hematemesis , melena , bleeding per rectum, constipation.
-No history of orthopnoea, paroxysmal nocturnal dyspnoea.
-No history of epigastric and retrosternal burning sensation
-No history of facial puffiness, decreased urine output , hematuria .
-No history of confusion, drowsiness or altered sleep rhythm.
PAST HISTORY:
6 months back , history of abdominal distension , bilateral pedal oedema,
for which he was admitted for 10 days which relieved with diuretics , abdominal paracentesis was done
No history of jaundice in the past
No history of blood transfusion, tattooing or injection drug abuse.
Not a known case of HTN , Diabetes , asthma , TB , epilepsy , CAD , thyroid diseases .
Personal history
He is a government employee who wakes up at 6 am ,does his daily routine and goes to his work . Most of the time he skips his breakfast and has lunch at around 2 pm to 3 pm and comes to home at around
6 pm.
Does his normal activities
At night:he consumes alcohol
This was his daily routine since 12 years .
He takes mixed diet
-Appetite : decreased since 6 days
-Sleep : adequate
-Bowel : regular
-Bladder :decreased urine output since 6 days
-Addictions :
chronic consumption of alcohol since 12 years daily , country liquor of 500 ml (nearly 110gm per day)
whisky of 150 ml per day (nearly 50gm per day)
Suggesting consumption of harmful dose of alcohol
- No h/o smoking
Family history
No history of similar complaints in any of his family members
GENERAL EXAMINATION
Patient was conscious,coherent and cooperative. Moderately built and nourished
-Pallor : present
- Icterus: absent
-Clubbing: absent
-Cyanosis: absent
-Lymphadenopathy: absent
-Edema : present
Bilateral
Pitting type
Painless
Extending upto the ankle
VITALS:
At presentation:
Temp : afebrile
BP : 110/90 mmHg in right arm, supine position
Pulse : 90 bpm
RR : 22cpm
Spo2 : 98% on room air
JVP is normal
Head to toe examination-
Hair is sparse
B/ l parotid enlargement - negative
No fetor hepaticus
No evidence of xanthoma and xanthelasma.
No gynaecomastia
Spider nevi - absent
No palmar erythema
No leuconychia
No duputryens contracture
Flapping tremors - absent
Axillary and pubic hair are normal
SYSTEMIC EXAMINATION
Gastrointestinal system examination
Oral cavity: normal
INSPECTION:
-Abdomen is uniformly distended
-dilated veins are seen
( Examined in standing position)
-Flanks are full
-Umbilicus appears flat
-No scars , sinuses
- No visible peristalsis
- Hernial orifices appear normal
PALPATION:
Done in supine position , with both lower limbs flexed and hands by side of body
Superficial palpation:
-No local rise of temperature , tenderness
-No guarding and rigidity
No local lymphadenopathy
-Abdominal girth : 92 cms
- Xiphisternum to umbilicus - 16 cms
-Public symphysis to umbilicus - 13cms
DEEP PALPATION
-Liver and spleen are not palpable.
- Shifting dullness present
- Fluid thrill absent
PERCUSSION:
Liver span -
upper border of liver dullness in 5 th intercoastal space in mid clavicular line, lower border could not be appreciated.
AUSCULTATION:
Bowel sounds were not clearly audible.
No bruit , venous hum or friction rub.
Examination of external genitalia
Appears normal
- No testicular atrophy.
RESPIRATORY SYSTEM:
-Bilateral air entry present
-Normal vesicular breath sounds heard ,
CARDIO VASCULAR EXAMINATION
-S1 S2 heard
-No murmurs
CENTRAL NERVOUS SYSTEM EXAMINATION
No focal neurological deficit.
PROVISIONAL DIAGNOSIS:
Chronic decompensated liver parenchymal disease
Etiology - ethanol
INVESTIGATIONS
CBP -
HB - 10.7
TLC - 19100,
PLT - 1.50 LAKH
LFT -
Total bilirubin - 1.63 mg/ dl
Direct bilirubin - 0.40mg/dl
SGOT - 34 IU/L
SGPT - 20 IU/L
ALP - 186 IU/L
Total protein - 5.4 gm/dl
Albumin - 2.06 gm/ dl
RBS- 70mg/dl
Ascitic fluid analysis -
SAAG - 1.70
(Serum albumin - 2.06
Ascitic albumin - 0.36)
Ascitic LDH - 120 IU/ L
Ascitic sugar - 52 mg/ dl
Ascitic protein - 0.8 g/dl
Appearance - Clear
Neutrophil count - 405.
Total count - 675
RBCS - Present.
PT - 16 Sec.
APTT - 32sec.
INR - 1.11
HEPATITIS SEROLOGY
HbsAg -negative
Hcv - negative.
USG ABDOMEN
Impression- liver normal size
Altered echotexture with surface irregularities present suggestive of chronic liver disease
FINAL DIAGNOSIS
Alcohol induced chronic decompensated liver disease, with High Saag , low protein ascites
MANAGEMENT
Ascitic tap for symptom relief
*Fluid restriction less than 1.5 L /day
*STRICT INPUT /OUTPUT CHARTING
• Salt restriction less than 2g/day
• Inj Lasix 40mg IV BD
• Syp lactulose 30ml PO
IV ceftraixone
DISCUSSION
Should the patient be started on treatment for preventing complications of portal hypertension ?
Prevention and treatment of hepatic encephalopathy:
Focusing on gut microbiota
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3520156/
It focuses on the role of starting on Rifaximin , in presence of co morbidities
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