53 year old male with c/o abdominal distension,SOB,, decreased urine output since 4-5 days
July 15th,2023.
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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.
Chief complaints:
53 year old Patient came to casuality with complaints of B/L pedal edema upto knees since 3 Months(resolving),abdominal distension,SOB, decreased urine output since 4-5 days.
HOPI:
-Patient was apparently asymptomatic 3 months ago back then he developed b/l pitting edema upto knees which was insidious in onset,gradually progressive in nature, continuous in nature,no diurnal variation,resolving with medication.
Abdominal distension is present since 4 to 5 days, insidious onset, gradually progressive in nature associated with discomfort and SOB.
SOB:4-5 days, aggravated with walking, talking relieved on lying in lateral position.
Orthopnea+
Dry cough+(mainly at night)
No chest pain, palpitations.
Decreased urine output since 4-5 days(yellow in colou with burning micturition)
Dark colour stools since one month
Echymosis present in left lumbar region since yesterday
Not a k/c/o HTN, DM -2, CVA, CAD, TB, asthma, epilepsy
K/c/o decompensated chronic liver disease with portal hypertension with thrombocytopenia,secondary to CLD.
Past history -
Not a k/c/o HTN, DM -2, CVA, CAD, TB, asthma, epilepsy
K/c/o decompensated chronic liver disease with portal hypertension with thrombocytopenia,secondary to CLD
Personal history:
Diet: mixed
Sleep - Adequate
Appetite - normal
Bowel movements - regular
Bladder movements- decreased urine output
Addictions -last alcohol intake 40 days back
Regular alcoholic since 20 years
Family history-
No significant family history
General examination -
Patient was conscious, coherent and co-operative.
pallor+
icterus+
Edema+
cyanosis, clubbing, lymphadenopathy absent
VITALS
Temperature - 98.8F
BP- 130/80mmhg
PR -112 bpm
RR-20 cpm
Spo2 99% room air
Grbs- 157
Investigations :
Chest x-ray
2d echo
Ecg:
Systemic examination:
Cvs - S1 S2 present ,no murmurs heard
R/s - bilateral air entry present
P/a:tender, soft
CNS examination:NFND
Provisional diagnosis:
Decompensated chronic liver disease
Treatment:
1)Fluid and salt restriction<1.5 gm/day
2)Inj monocef 1gm/IV/BD
3)T.lasilla 50 mg/PO/OD(if sbp>90mmhg)
4)syrup nemaffin 15ml/PO/BD( to maintain 4-5 stools per day)
5) abdominal girth and weight maintainece
6) Vitals monitoring 4th hourly
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