Medicine case discussion

 This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.

Here we discuss our individual patient problems through series of inputs from  available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This E-blog also reflects my patient's centred online learning portfolio.

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 a diagnosis and treatment plan.

A 35yr old male patient, labourer by occupation came to the OPD with c/c of 

1. Loss Of Appetite

2. Abdominal Distension

3. SOB after taking Food

all since 15 days

History of present illness

Patient was apparently asymptomatic 15 days back after which he developed Abdominal Distention which is Progressive in nature associated with loss of appetite and increase on taking liquids and food. 

Patient also complaints of B/L Pedal edema extending till ankle region 7days back and decreased after taking Diuretics. 

also c/o Dark coloured stools and SOBNo H/O of Fever, Orthopnea, PND, Palpitations, Syncope. 

3/7/2021

This patient came to opd in view of fever spikes sir(we thought it could be due to SBP ).He came back 6-8days after discharge.And then His RTPCR for COVID turned out to be positive.This happened around 10days back sir.Currently he is in home isolation and is using Cotrimoxazole tablets for Sbp

Past h/o

5yrs back pt had h/o pain abdomen with calceous cholilithisasis

1yr back Ascetic tap done

h/o blood transfusion past 1-2 years

K/c/o DM-T2 since 3years

Personal history

Diet-mixed

Bowel and bladder-regular

Appetite-normal

Sleep-adequate 

Addictions-

Chronic Alcohol since 10 yrs 

Daily 90ml

Family history 

-insignificant

General examination

Patient is examined by taking informed consent

Patient is conscious,coherent,cooperative and well oriented to time,place and person

He is poorly built and nourished

Pallor-absent

Icterus-absent

Cyanosis-absent

Clubbing-absent

Lymphadenopathy-absent

Edema-present

Vitals

On 15/6/21

Temperature-98.7F

Bp-90/50mmhg

Pulse-84bpm

Respiratory rate-18cpm

Systemic examination 

Abdominal examination

-abdomen distension around umbicus

-soft and non tender

-no organomegaly

-bowel sounds were heard

Cvs

-s1 and s2 heard

No murmurs heard

Respiratory system

-bilateral air entry

-vesicular breath sounds

CNS

-oriented to time,place and person

Investigations

 

Provisional diagnosis 

Chronic decompensated liver disease 

Treatment given

Tab lasix20mg BD

Tab aldactone  50mg BD

Fluid restriction <1lit/day

Salt restriction<2g/day

Grbs monitoring 6th hourly

Course in hospital

Patient is a chronic alcoholic came with complaints of abdominal distension and weakness.USG showed moderate ascitic fluid.patient is a diabetic and started on HAI .diagnostic ascitic tap was done.

Advice on discharge

1.fluid restriction <1.5lit/day

2.salt restriction <2gm/day

3.inj.hai sc/Tid 6U

4.Tab.aldactone 50mg/po/od

5.tab.bacfen xl 20mg/po//hs for 10days

6.tab.benxl xl po/od for 10days

7.syp.lactulose 15ml/po/sos constipation 

8.Tab.MVT po/od for 15days

9.Tab.Augmentin 625mg/tid for 5days

Follow up 

Review after 10days