GENERAL MEDICINE CASE
Name: Cheera Preethi
30 year old male came to OPD with Pedal edema and abdominal distension since 10 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. This elog reflects my patient centered online learning portfolio.
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.
30 year old male came to OPD with Pedal edema and abdominal distension since 10 days.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 year and then he developed pedal oedema is insidious in onset,gradually progressive.
Bilateral pitting type associated with abdominal distension.
1 year back he had pain abdomen - diffuse type, not associated with vomitings - stopped drinking due to pain and got treatment from local RMP.
After the pain subsided, he started drinking again.
2 months back,there is H/O yellowish discoloration of eyes, bilateral pedal edema, pain abdomen
PAST HISTORY:
H/O of RTA in 2007 which led to leg fracture.
H/O of RTA in 2013 due to which he went into coma for 3 days.
2 years back he was diagnosed with Fatty liver.
Patient was COVID Positive 4 months back.
3 months back he was admitted in our hospital with similar complaints and he was treated with
1)Tab.lasix 40 Mg ,PO/OD
2)Tab.Aldactone 50 mg BD
3) Tab.Pantop 40mg PO/OD
4)Tab.Udiliv 300mg PO/OD
5)Syp.Hepamerz BD
On 06/08/2021:
Hb:7.5gm/dl
Tlc:28000
LFT:
Total bilirubin:13.18mg/dl
Direct Bilirubin:7.16mg/dl
ALP:181
Albumin:2.24
A/G:0.61
Not a K/C/O HTN/DM/BA/TB/Epilepsy/CAD
PERSONAL HISTORY:
Diet- mixed
Sleep-adequate
Appetite-decreased
Bowel and bladder habits- irregular
Addictions-
Alcohol: Regular intake of 180-360 ml/day since 10 yrs -- stopped 4 months back
Smoking: 5-6 per day since 10 yrs -- stopped 4 months back.
FAMILY HISTORY:
Not Significant
GENERAL EXAMINATION:
Pt is C/C/C
Mild pallor present
Icterus present
Bilateral Oedema-pitting type of feet
Mild Malnutrition
No clubbing/koilonychia/lymphadenopathy
Vitals:
Afebrile,
BP;120/70mmhg
PR:100Bpm
RR:19Cpm
Spo2:98%
SYSTEMIC EXAMINATION:
CVS:
S1 S2 heard
No murmurs
RS:
BAE+
NVBS+
Trachea-central
No added sounds
No dyspnoea/wheeze
CNS: NAD
P/A:
Shape of abdomen-distended
Hernial orifices normal
No tenderness or palpable mass
Shifting dullness+
Liver and spleen not palpable
Bowel sounds heard
INVESTIGATIONS:
23/09/2021
1. Hemogram:
- Hb= 6.8 gm%
- TLC= 10,300
- PCV= 20.1
- MCH= 34.5
- RBC= 1.97 million/cc
- PLATELETS= 1.70 lakhs/cumm
3.Serum Electrolytes:
Sodium= 135 mEq/L
Potassium= 4 mEq/L
Chloride= 102 mEq/L
4. LFT:
Total bilirubin=4.55
Direct bilirubin=3.05
SGOT=37
ALP=338
Albumin=2.0
Total Protein:5.0
A/G Ratio=0.66
PT-18sec
INR:1.2
Aptt:36sec
Blood urea:16
Sr creatinine:0.8
Sr LDH:290
Sr.iron:62
Sr.ferritin:595
Sr.albumin:2.6
Ascitic Fluid;
Sugar:172
Protein:1.1
Amylase:8.6
LDH;47
Albumin:0.43
SAAG:2.17
Ascitic fluid cytology:
TC:15 cells
L:90%
N:10%
RBC: Few
ECG:
Chest xray:
Ultrasound:
Provisional diagnosis:
Chronic Liver disease secondary to alcohol
TREATMENT GIVEN:
1. Fluid restriction <2 L/day
2. Inj. Lasix 40 mg IV BD 8am and 4 pm
3. Tab. Spironolactone 500 mg OD at 8 am
4. Inj. Thiamine 100 mg in 100 ml NS IV TID
5. Weight monitoring daily
6. Abdominal girth daily
7. Input/Output charting
8. 2 egg whites/day
9. Proteiney powder 2 scoops in 1 glass
Soap notes:
24/09/2021
Subjective- Pedal edema present and abdominal distension present
Objective
Temp: 100F
Bp: 120/70 mm hg.
PR:86bpm
GRBS: 112mg/dl.
Spo2:99%
Abdominal girth:78cm
Weight:51.4kgs
Assessment
Chronic liver disease secondary to alcohol.
Ascitic Fluid;
Sugar:172
Protein:1.1
Amylase:8.6
LDH;47
Albumin:0.43
SAAG:2.17
Ascitic fluid cytology:
TC:15 cells
L:90%
N:10%
RBC: Few
Plan of care:
1)Fluid restriction <2L/Day
2. Inj. Lasix 40 mg IV BD 8am and 4 pm
3. Tab. Spironolactone 500 mg OD at 8 am
4. Inj. Thiamine 100 mg in 100 ml NS IV TID
5. Weight monitoring daily
6. Abdominal girth daily
7. Input/Output charting
8. 2 egg whites/day
9. Proteiney powder 2 scoops in 1 glass
This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians signed informed consent. This elog reflects my patient centered online learning portfolio.
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.
30 year old male came to OPD with Pedal edema and abdominal distension since 10 days.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 year and then he developed pedal oedema is insidious in onset,gradually progressive.
Bilateral pitting type associated with abdominal distension.
1 year back he had pain abdomen - diffuse type, not associated with vomitings - stopped drinking due to pain and got treatment from local RMP.
After the pain subsided, he started drinking again.
2 months back,there is H/O yellowish discoloration of eyes, bilateral pedal edema, pain abdomen
PAST HISTORY:
H/O of RTA in 2007 which led to leg fracture.
H/O of RTA in 2013 due to which he went into coma for 3 days.
2 years back he was diagnosed with Fatty liver.
Patient was COVID Positive 4 months back.
3 months back he was admitted in our hospital with similar complaints and he was treated with
1)Tab.lasix 40 Mg ,PO/OD
2)Tab.Aldactone 50 mg BD
3) Tab.Pantop 40mg PO/OD
4)Tab.Udiliv 300mg PO/OD
5)Syp.Hepamerz BD
On 06/08/2021:
Hb:7.5gm/dl
Tlc:28000
LFT:
Total bilirubin:13.18mg/dl
Direct Bilirubin:7.16mg/dl
ALP:181
Albumin:2.24
A/G:0.61
Not a K/C/O HTN/DM/BA/TB/Epilepsy/CAD
PERSONAL HISTORY:
Diet- mixed
Sleep-adequate
Appetite-decreased
Bowel and bladder habits- irregular
Addictions-
Alcohol: Regular intake of 180-360 ml/day since 10 yrs -- stopped 4 months back
Smoking: 5-6 per day since 10 yrs -- stopped 4 months back.
FAMILY HISTORY:
Not Significant
GENERAL EXAMINATION:
Pt is C/C/C
Mild pallor present
Icterus present
Bilateral Oedema-pitting type of feet
Mild Malnutrition
No clubbing/koilonychia/lymphadenopathy
Vitals:
Afebrile,
BP;120/70mmhg
PR:100Bpm
RR:19Cpm
Spo2:98%
SYSTEMIC EXAMINATION:
CVS:
S1 S2 heard
No murmurs
RS:
BAE+
NVBS+
Trachea-central
No added sounds
No dyspnoea/wheeze
CNS: NAD
P/A:
Shape of abdomen-distended
Hernial orifices normal
No tenderness or palpable mass
Shifting dullness+
Liver and spleen not palpable
Bowel sounds heard
INVESTIGATIONS:
23/09/2021
1. Hemogram:
- Hb= 6.8 gm%
- TLC= 10,300
- PCV= 20.1
- MCH= 34.5
- RBC= 1.97 million/cc
- PLATELETS= 1.70 lakhs/cumm
3.Serum Electrolytes:
Sodium= 135 mEq/L
Potassium= 4 mEq/L
Chloride= 102 mEq/L
4. LFT:
Total bilirubin=4.55
Direct bilirubin=3.05
SGOT=37
ALP=338
Albumin=2.0
Total Protein:5.0
A/G Ratio=0.66
PT-18sec
INR:1.2
Aptt:36sec
Blood urea:16
Sr creatinine:0.8
Sr LDH:290
Sr.iron:62
Sr.ferritin:595
Sr.albumin:2.6
Ascitic Fluid;
Sugar:172
Protein:1.1
Amylase:8.6
LDH;47
Albumin:0.43
SAAG:2.17
Ascitic fluid cytology:
TC:15 cells
L:90%
N:10%
RBC: Few
ECG:
Chest xray:
Ultrasound:
Provisional diagnosis:
Chronic Liver disease secondary to alcohol
TREATMENT GIVEN:
1. Fluid restriction <2 L/day
2. Inj. Lasix 40 mg IV BD 8am and 4 pm
3. Tab. Spironolactone 500 mg OD at 8 am
4. Inj. Thiamine 100 mg in 100 ml NS IV TID
5. Weight monitoring daily
6. Abdominal girth daily
7. Input/Output charting
8. 2 egg whites/day
9. Proteiney powder 2 scoops in 1 glass
Soap notes:
24/09/2021
Subjective- Pedal edema present and abdominal distension present
Objective
Temp: 100F
Bp: 120/70 mm hg.
PR:86bpm
GRBS: 112mg/dl.
Spo2:99%
Abdominal girth:78cm
Weight:51.4kgs
Assessment
Chronic liver disease secondary to alcohol.
Ascitic Fluid;
Sugar:172
Protein:1.1
Amylase:8.6
LDH;47
Albumin:0.43
SAAG:2.17
Ascitic fluid cytology:
TC:15 cells
L:90%
N:10%
RBC: Few
Plan of care:
1)Fluid restriction <2L/Day
2. Inj. Lasix 40 mg IV BD 8am and 4 pm
3. Tab. Spironolactone 500 mg OD at 8 am
4. Inj. Thiamine 100 mg in 100 ml NS IV TID
5. Weight monitoring daily
6. Abdominal girth daily
7. Input/Output charting
8. 2 egg whites/day
9. Proteiney powder 2 scoops in 1 glass
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