45 yr old male with abdominal distension since 4 months

This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.


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

N.sahithi

Roll no -107


Case history-

A 45 years old male came with 

-c/o Abdominal distension since 4months

- SOB On  and off  since 4 months


 History of presenting illness-

Patient was apparently asymptomatic 4 months back then he developed abdominal distension which was ,Insidious in onset, gradually progressive in nature .

Since 1 month abdominal distension is progressive in nature for which he visited government hospital was diagnosed as ALD with portal Hypertension with Decompensated liver disease with Hepatic encephalopathy Grade 1 with Right pleural effusion mild. 

Pedal edema since 4 months insidious in onset gradually progressive ,relieved at night and aggrevated in morning (pitting type).

Sob present even at rest,orthopnea,PND present. 

No chest pain , palpitations.

C/o decreased urine output since 1 month since then patient is on Foleys catheter and 2 lit ascitic tap was done

PAST HISTORY

K/c/o Type 2 DM since 15 years and on medications 

Operated for iliospoas Abscess 10 months ago 

Not a  K/C/0 HTN,CAD, EPILEPSY, ASTHMA, TB , CVA ,THYROID DISORDERS 

PERSONAL HISTORY -

Appetite: Normal 

Diet-mixed

Bowel-Regular

Bladder- Decreased urine output since 1 month

Addictions:

Regular alcoholic since 15yrs

Occassional alcoholic since 4yrs (1- 2 times/ month)

2months ago patient consumed alcohol for 10days continuously 


General examination-

No pallor ,icterus, cyanosis, clubbing , lymphadenopathy 

Vitals-

Bp -110/70 mm hg

PR-96bpm

Temp-96.4 f

RR- 18cpm

SPO2- 98%on RA

Grbs - 125mg/dl


Systemic examination-

CVS-s1, s2 heard , no murmurs

RS-BAE present 

CNS- No focal neurological deficit 

 P/A- Inspection:


Round, with distention


Umbilicus: protruded


No visible pulsation,peristalsis, dilated veins and localized swellings.


Palpation: 


Soft, distended, non tender 


No signs of organomegally


Percussion: 


fluid thrill present 


Auscultation: 


Bowel sounds heard .








Diagnosis:

Chronic Decompensated liver disease with k/c/o Dm ll since 15yrs.

Investigations:

















Fever chart:



Ascitic tap:

Therapeutic 




Treatment:

1.INJ Optineuron 1amp+100ml Ns /iv/OD
2.Tab lasilactone 20/50mg po BD 8am --- 4pm
3.syp.lactulose 15ml po BD 
4.syp Hepamerz 10ml po BD
5.High protein diet 2 egg whites/ day
6.protein powder 2tsps in 1 glass of water TID
7.Fluid restriction <2lit /day
8.salt restriction <2g /day

Follow up:
On 30/04/23

S  
C/o abdominal distention (discomfort), shortness of breath present (reduced)
Stools not passed 
 
O: 

Patient is conscious coherent and cooperative 
pallor - present ,pedal edema present 
No icterus , clubbing, cyanosis,lymphadenopathy 

Vitals : 

BP- 140/80mmhg
PR -82bpm
RR-28cpm
Spo2 99% at room air 
GRBS - 110mg/dl
Temperature 98°F  
I/O :- 950ml/1150 ml

Cvs: s1,s2 heard ,no Murmurs,jvp not raised 
Rs: BAE,no added sounds ,NVBS, 

P/A: soft, distended, bowel sounds can be heard, fluid thrill present 

CNS:

Pt is conscious, 

Speech is normal

No meningeal signs

Normal cranial nerve examination, motor system, sensory system

Gcs: E4,V5,M6

 Reflexes:



       R L


B ++ ++

T ++ ++

S ++ ++

K ++ ++

A ++ ++

P Flexor Flexor  

A: 
Chronic decompensated liver disease ( since 4 months)
K/c/o DM type 2 since 15 yrs
Anemia under evaluation
Chronic kidney disease  

P: 
1.fluid restriction < 2L/day
2.salt restriction < 2g/day 
3.INJ. optineuron 1amp +100 ml NS/IV/OD
4.Tab spiranolactone 25mg/po/bd 
5.syp lactulose 10ml/po/tid 
6.high protein diet 2egg whites/day 
7.protein powder 2tsps in 1 glass of water /po/tid 
8.strict I/O charting
9.vitals monitoring 4th hourly
10.GRBS monitoring 6th hourly


On 01/05/24
-
S  
C/o abdominal distention (discomfort), shortness of breath present (reduced)
Stools not passed 
 
O: 

Patient is conscious coherent and cooperative 
pallor - present ,pedal edema present 
No icterus , clubbing, cyanosis,lymphadenopathy 

Vitals : 

BP- 140/80mmhg
PR -84bpm
RR-18cpm
Spo2 98% at room air 
GRBS - 182mg/dl
Temperature 98°F  
I/O :- 900ml/1550 ml

Cvs: s1,s2 heard ,no Murmurs,jvp not raised 
Rs: BAE,no added sounds ,NVBS, 

P/A:
Inspection:

Round, with distention

Umbilicus: Inverted

No visible pulsation,peristalsis, dilated veins and localized swellings.


Palpation: 


Soft, distended,non tender


No signs of organomegally


Percussion: 


 fluid thrill, shifting dullness present 

Ascultation: bowel sounds can be heard

CNS:

Pt is conscious, 

Speech is normal

No meningeal signs

Normal cranial nerve examination, motor system, sensory system

Gcs: E4,V5,M6

 Reflexes:



       R L


B ++ ++

T ++ ++

S ++ ++

K ++ ++

A ++ ++

P Flexor Flexor  

A: 
Acute on Chronic decompensated liver disease 
Normocytic Normochrimic Anaemia (Hypoproliferative)
?Anemia of chronic disease
HRS-Chronic kidney disease ? Diabetic Nephropathy with ? Porto pulmonary HTN
  

P: 
1.fluid restriction < 2L/day
2.salt restriction < 2g/day 
3.INJ. optineuron 1amp +100 ml NS/IV/OD
4.Tab spiranolactone 2t5mg/po/bd 
5.Tab udiliv 300mg/PO/BD
6.T.Rifagut 550mg/PO/BD
7.syp lactulose 10ml/po/tid
8. Syp.Hepamerz 10ml/PO/BD
8.high protein diet 2egg whites/day 
9.protein powder 2tsps in 1 glass of water /po/tid 
10.Inj.vit k 1amp +100ml IV/OD
11.strict I/O charting
12.vitals monitoring 4th hourly
13.GRBS monitoring 6th hourly


02.05.2023

S  
C/o abdominal distention (discomfort), shortness of breath present (reduced)
2episodes of stools passed 
 
O: 

Patient is conscious coherent and cooperative 
pallor - present ,pedal edema present 
No icterus , clubbing, cyanosis,lymphadenopathy 

Vitals : 

BP- 140/100mmhg
PR -90bpm
RR-20cpm
Spo2 98% at room air 
GRBS - 131mg/dl
Temperature 98°F  
I/O :- 750ml/500 ml

Cvs: s1,s2 heard ,no Murmurs,jvp not raised 
Rs: BAE,no added sounds ,NVBS, 

P/A: soft, distended, mild tenderness in both iliac fossa 

CNS:

Pt is conscious, 

Speech is normal

No meningeal signs

Normal cranial nerve examination, motor system, sensory system

Gcs: E4,V5,M6

 Reflexes:



       R L


B ++ ++

T ++ ++

S ++ ++

K ++ ++

A ++ ++

P Flexor Flexor  

A: 
Acute on Chronic decompensated liver disease 
Normocytic Normochrimic Anaemia (Hypoproliferative)
?Anemia of chronic disease
HRS-Chronic kidney disease ? Diabetic Nephropathy with ? Porto pulmonary HTN
  

P: 
1.fluid restriction < 2L/day
2.salt restriction < 2g/day 
3.INJ. optineuron 1amp +100 ml NS/IV/OD
4.Tab spiranolactone 25mg/po/bd 
5.syp lactulose 10ml/po/tid
6.high protein diet 2egg whites/day 
7.protein powder 2tsps in 1 glass of water /po/tid 
8.Inj.vit k 1amp +100ml IV/OD
9.strict I/O charting
10.vitals monitoring 
11.GRBS monitoring 6th hourly 
12.Tab Clinidipine 10mg po/od

Comments

Post a Comment

Popular posts from this blog

A 27yrs old male came to casuality with c/o headache

Image
  Sahithi.N This is an 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. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. 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  Case history: Cheif complaints: . A 27yrs old male came to casuality with c/o headache  and giddiness on and off since 3yrs HOPI:  Patient was apparently asymptomatic 3yrs back then he sustained...
Read more

Internship assessment

  INTERNSHIP ASSESSMENT  Sahithi Nalabolu  June 15, 2023 I have been posted in General Medicine  from  14th April to 12 th june FIRST 15 DAYS UNIT DUTIES (12-02-2023 TO 26/02/2023) NEXT 15 DAYS PSYCHAITRY (27/02/2023 TO 13/03/2023) NEXT 15 DAYS PERIPHERALS (14/03/2023 TO 29/03/2023) LAST 15 DAYS UNIT DUTIES (29/03/2023 TO 13/04/2024) UNIT DUTY :  I have been posted intially into unit  Op duties: Attended my all the 4 op duties and Audit duties I took history of many  patients and examined them clinically. Learnt basic management for common conditions like Hypertension,Diabetes mellitus,chest pain , migrane . And I made PaJR groups and blogs for admitted patients. Blog 1: https://sahithinalaboluelog.blogspot.com/2023/05/45-yr-old-male-with-abdominal.html A 45 years old male came with   -c/o Abdominal distension since 4months - SOB On  and off  since 4 months Learning points: Ascitic tap  Learnt about SAAG  Learnt the causes...
Read more

Internal assessment.

Image
 N.sahithi  ROLL NO:96 Q1) define bone density, how it is measured?what are the causes ,clinical features ,diagnosis and management of osteoporosis? https://rishik37.blogspot.com/2021/08/gm-elog-case-7.html Bone density is amount of bone mineral in bone tissue. *Test used to measure bone mineral density is dual energy xray absorptiometry DEXA . Causes:  Caucasian or Asian race Malabsorption (nutrients are not properly absorbed from the gastrointestinal system) from bowel diseases, such as celiac sprue that can be associated with skin diseases, such as dermatitis herpetiformis Low estrogen levels in women (which may occur in menopause or with early surgical removal of both ovaries) Low testosterone levels in men (hypogonadism) Chronic inflammation, due to chronic inflammatory arthritis or diseases, such as rheumatoid arthritis or liver diseases Immobility, such as after a stroke, or from any condition that interferes with walking. Hyperthyroidism and hyperparathyroidism....
Read more