27 year old male with complaints of loss of apetite since 20 days

 

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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.

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

Blood urea

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

 

 

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