GENERAL MEDICINE FINAL PRACTICAL LONG CASE

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HALL TICKET NUMBER: 1701006078

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.

CASE DISCUSSION:

A 50 years old gentleman, farmer by occupation, resident of Yadadri Bhuvanagiri district came to the hospital with the following cheif complaints. 

CHEIF COMPLAINTS:

• Distension of abdomen since 7 days
• Pain in the abdomen since 4 days and
• Pedal edema since 3 days

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 6 months back then he developed jaundice and he was treated for jaundice by a private medical practitioner. After that he was normal till last week.

He developed distension of abdomen 7 days back, which is insidious in onset, gradually progressive, aggravated in last 4 days and progressed to the present size. No aggravating and releiving factors.

He complaints of abdominal pain from last 3 days which is insidious in onset, gradually progressive, in the epigastrium and right hypochondrial regions without any aggravating and releiving factors. 

He also complains of swelling in both feet of Grade II since 3 days which is insidious in onset, gradually progressive, pitting type without any aggravating and releiving factors.

NO history of hemetemesis, melena, vomitings, nausea

NO history of bulky stools, black tarry and clay colored stools

NO history of fever with chills and rigor

NO history of anorexia, facial puffiness, generalised edema

NO history of evening rise of temperature, cough, night sweats

NO history of orthopnea, palpitations 

NO history of loss of weight

PAST HISTORY:

NO history of similar complaints in the past.

Not a known case of Diabetes, Hypertension, Tuberculosis, Asthma, epilepsy, hypothyroidism/hyperthyroidism, COPD, CAD and blood transfusions. 

FAMILY HISTORY:

None of the patient's parents, siblings or first degree relatives have or had similar complaints or any significant comorbidities.

PERSONAL HISTORY:

Appetite: reduced

Diet: mixed

Bladder habits: frequency of urine is reduced since 2 days

Bowel habits: constipation since last 4 days

Sleep: Adequate 

Addictions:

• Beedi smoker: for past 30 years. 4-5 beedis per day

• Alcoholic: chronic alcoholic previously 

From last one year, occasional alcoholic -  consumes 90ml of whiskey 

• Toddy: occasionally 

GENERAL PHYSICAL EXAMINATION:

Patient is conscious, coherent and cooperative.

Examined after taking vaild informed consent in a well enlightened room.

Built and nourishment: moderately built and moderately nourished 

Pallor: No pallor

Icterus: No icterus

Cyanosis: No cyanosis 

Clubbing: No clubbing 

Generalised lymphadenopathy: No generalised lymphadenopathy 

Pedal edema: Grade II bilateral pedal edema

VITALS:

Temperature: afebrile

Pulse rate: 90bpm, regular rhythm, normal volume

Respiratory Rate: 22 breathes per minute, abdominothoracic type

Blood Pressure: 130/90 mm of Hg in right arm in sitting position 

GRBS: 90mg/dl

SpO2: 98% at room air

TREMORS: present

SYSTEMIC EXAMINATION: 

PER ABDOMINAL EXAMINATION: 

INSPECTION: 9 regions

Shape of the abdomen: globular

Distension of abdomen: distended

Flanks: full

Umbilicus: 

       Shape: everted

       Position: central

       Herniations: absent

       Discharge: absent

Skin over abdomen: smooth and shiny

No pigmentations, discolorations, scars, sinuses, fistulae, engorged veins, visible pulsations, hernial orifices, 

Genitals: normal

PALPATION: 

No local rise of temperature 

Tenderness: present in the epigastrium region

Hepatomegaly: absent

Splenomegaly: absent

Guarding: present 

Rigidity: absent

Renal angle tenderness: absent

No rebound tenderness

No visible peristalsis 

FLUID THRILL(with extended legs): POSITIVE 

PERCUSSION:

In supine position,

  Tympanic note - heard at midline of the abdomen 

  Dull note - heard at flanks

Shifting dullness: POSITIVE 

Liver span : could not be detected

AUSCULTATION:

Bowel sounds: decreased

No bruits

CARDIOVASCULAR SYSTEM- 

Inspection- 

The chest wall is bilaterally symmetrical

No dilated veins, scars or sinuses are seen

Apical impulse or pulsations cannot be appreciated 

Palpation-

Apical impulse is felt in the fifth intercostal space, 1 cm medial to the midclavicular line

No parasternal heave felt

No thrill felt

Percussion- 

Right and left borders of the heart are percussed 

Auscultation-

S1 and S2 heard, no added thrills and murmurs are heard

RESPIRATORY SYSTEM:

Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: resonant bilaterally 

Auscultation:

 bilateral air entry present. Normal vesicular breath sounds heard.

CENTRAL NERVOUS SYSTEM 

Higher mental functions :-

Patient is conscious ,coherent and cooperative 

Right handed individual

Memory - immediate , short term and long term memory are assessed and are normal 

Language and speech are normal

Cranial nerves :- intact 

Sensory system :- 

Sensation                right        left

 Touch                       felt          felt

Pressure                    felt          felt 

Pain 

-superficial                felt          felt

-deep                           felt          felt

Proprioception

-joint position             ✔            ✔

-joint movement        ✔            ✔

Temperature             felt         felt 

Vibration                    felt         felt

Stereognosis                ✔            ✔

Motor system 

                                     Right.      Left

BULK 

Upper limbs.                  N        N

Lower limbs                    N       N

TONE

 Upper limbs.                   N      N

 Lower limbs.                  N        N

POWER

 Upper limbs.                 5/5       5/5

 Lower limbs                  5/5       5/5

Gait :- Normal

Superficial and deep reflexes are elicited

No signs ssuggestive of cerebellar dysfunction

INVESTIGATIONS:

1. HEMOGRAM: 

Hemoglobin : 9.8 g/dl

TLC : 7,200

Neutrophils : 49%

Lymphocytes : 40%

Eosinophils : 1%

Basophils : 0%

PCV : 27.4%

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

2. Serology : 

HbsAg : Negative

HIV : Negative

3. ESR :

15mm/1st hour

4. Prothrombin time : 16 sec

5. APTT : 32 sec

6. Serum electrolytes :

Sodium : 133 mEq/L

Potassium : 3 mEq/L

Chloride : 94 mEq/L

7. Blood Urea : 12 mg/dl

8. Serum Creatinine : 0.8 mg/dl

9. LFT :

Total Bilirubin : 2.22 mg/dl

Direct Bilirubin : 1.13 mg/dl

AST : 147 IU/L

ALT : 48 IU/L

ALP : 204 IU/L

Total proteins : 6.3 g/dl

Serum albumin : 3 g/dl

A/G ratio : 0.9

10. Ascitic fluid :

Protein : 0.6 g/dl

Albumin : 0.34 g/dl

Sugar : 95 mg/dl

LDH : 29.3 IU/L

SAAG : 2.66 g/dl

ASCITIC FLUID CYTOLOGY:

Microscopy:

Cytology smear study shows few scattered lymphocytes, reactive mesothelial cells against a granular eosinophilic proteinaceous background.

No atypical cells are seen.

Impression: negative for malignancy 

ASCITIC FLUID CULTURE AND SENSITIVITY REPORT:

ZN staining: No acid fast bacilli seen.

Few epithelial cells with no inflammatory cells seen. No organisms seen.

No growth after 48 hours of aerobic incubation

ULTRASONOGRAPHY:

Coarse echotexture and irregular surface of liver - Chronic liver disease

Gross ascites

Gallbladder sludge

ELECTROCARDIOGRAPHY:

CHEST RADIOGRAPHY:

ASCITIC FLUID TAPPING: Done twice 

Severity of liver disease:

CHILD-PUGH-TURCOTTE SCORING SYSTEM:

Parameter                                       points asigned

                                                     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

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

PROVISIONAL DIAGNOSIS:

This is a case of Decompensated Chronic liver disease with ascites, probably secondary to chronic alcoholism.

TREATMENT:

1. Inj. PANTOPRAZOLE 40 mg IV OD

2. Inj. LASIX 40 my IV BD

3. Inj. THIAMINE 1 Amp in 100 ml IV TID

4. Tab. SPIRONOLACTONE 50 mg BB

5. Syrup. LACTULOSE 15 ml HS

6. Syrup. POTCHLOR 10ml PO TID

7. Fluid restriction less than 1L/day

8. Salt restriction less than 2g/day