27 year old male with complaints of loss of apetite since 20 days
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
plan.
A 27 year old
male resident of chityala daily wage worker by occupation came to our hospital
with chief complaints of loss of appetite since 20 days, blood in urine since 10
days pedal edema since 10 days.
HISTORY OF
PRESETING ILLNESS
Patient was
apparently asymptomatic 20 days back then he had a loss of appetite for which
he went to the hospital and diagnosed as chronic liver disease, splenomegaly associated
with portal hypertension and took medication. Later on he developed hematuria
since 10 days, he saw red colour in urine uniform in distribution not associated
with pain no known aggravating and relieving factors and pedal edema which is pitting
type it aggravated on walking or standing for long hours it was relieved on
taking rest for sometime.
No history of abdominal pain,vomiting, diarrhoea,
hematemesis, weight loss, constipation, dysphagia, melena, heart burn.
No history of decreased and increased micturition
urine output, burning micturition
No history of chest pain, cough, cold, orthopnoea,
palpitations, sweating, peripheral nerve disease
PAST HISTORY
Similar complaints in the past 1 year back where he was
treated accordingly
History of jaundice 4 years back used oral medications
Not a known case of epilepsy, hypertension, diabetes, tuberculosis, CVA,
coronary artery disease
FAMILY HISTORY
No similar complaints in the family
PERSONAL HISTORY
Diet: Mixed
Sleep: Disturbed
Appetite: Decreased
Bowel movements: Normal
Bladder movements: Normal
Alcohol: Since 6 years daily 180 ml
GENERAL EXAMINATION
Patient is conscious, coherent, and comfortable
No pallor, Icterus present, clubbing present, no lymphadenopathy, pedal edema
present, no cyanosis
VITALS
Temperature: 98.6F
Pulse rate: 80 bpm
Respiratory rate: 17 cpm
Blood pressure: 110/70 mmHg
ABDOMEN EXAMINATION
Shape of abdomen scaphoid, flanks are normal, umbilicus
is central and inverted, appendectomy scar is present, no sinuses, dilated
veins
Movement of abdominal wall equal and symmetrical
No visible gastric peristalsis
Intact hernial orifices
PALPATION
No tenderness, no local rise of temperature
LIVER: Non tender, lower border of the liver could be palpated upon inspiration
in the right hypochondrium, I could not palpate the upper border on palpation
SPLEEN: Not palpable
KIDNEY: Non tender, bimanually palpable in the right and left lumbar regions.
ABDOMINAL GIRTH: On inspiration 84cms and on expiration 79cms
PERCUSSION
Shifting dullness not present
Fluid thrill not present
Liver span checked and seen 11cms
No hepatomegaly, No splenomegaly
AUSCULATATION
Bowel sounds heard 8 times in a minute
No bruits heard
CARDIOVASCULAR EXAMINATION
S1, S2 heard, No murmurs
RESPIRATORY SYSTEM
Non vesicular breath sounds heard on both the sides
no added sounds
CENTRAL NERVOUS SYSTEM
Patient is conscious, coherent, and comfortable
Cranial nerves intact
Sensory system intact
Motor system tone, bulk, and power normal on all four limbs
DIAGNOSIS
Decompensated liver disease with with alcohol dependence
syndrome and anemia and hypotonic hyponatremia diuretic induced
INVESTIGATIONS
Hemogram
Complete urine examination
APTT
PT
Random blood sugar
Serum creatinine
Serum electrolytes
Liver function test
Ultrasound
ECG
TREATMENT
IV fluid
Tab. Doxy
T.Udiliv
T. Orofer
T. Oxazepam
Syp laculose
Syp Hepamerz
Fudic cream
Comments
Post a Comment