1801006110 -SHORT CASE

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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:

45 year old male who is a resident of Nalgonda and Sheperd  by occupation presented to the hospital with chief complaints 

• shortness of breath and  cough since 6 years, 

• abdominal distention , facial puffiness , pedal edema since 3 years

HISTORY OF PRESENT ILLNESS 

patient was apparently asymptomatic 6 year back and then he developed shortness of breath which is insidious in onset gradually progressive which is grade 2 ( NYHA grading ) .

Then he developed cough which is intermittent ,productive with sputum which is yellow in colour and non blood stained.

There is history of abdominal distention since 3 years which is insidious in onset and gradually progressive  then he consulted a local doctor and used medications but then its not relieved and continued to progress  for which he came here .

He also has  history of  facial puffiness and pedal edema for  which he is  on medications .

History of constipation since 1 year .

No history of vomiting ,melena ,fever, jaundice , orthopnoea , PND, chest pain , palpitations , weight loss.

DAILY ROUTINE:

He wakes up in the morning by 6'o clock and goes to the work by 9'o clock  after having breakfast  and  he will have his lunch by 1 in the afternoon and continues with the work then he goes back to home by 6 pm in the evening .

PAST HISTORY:

No similar complaints in the past 

Not a known case  diabetes , hypertension , asthma, TB, epilepsy 

He has a H/o liver infection 1year ago which had got relieved with medication.

Treatment history:

Right IOL implantation in 2021

Family history:

Not relevant

Personal history:

Diet : mixed 

Appetite-normal

Sleep-inadequate 

Bowel and bladder movements-constipation since 1year,urine output is normal

Addictions-He had H/o alcohol intake since his childhood 200ml/day and abstinence of alcohol from 1year

H/o smoking since childhood  18 cigars per day

GENERAL EXAMINATION:

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

Moderately built and nourished

Pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy:absent

Pedal edema: B/L pedal edema is present

 

VITALS : 

Bp:130/70 mm/hg

PR:88/min

RR: 17 cpm

Temperature: afebrile 

Spo2: 96%

Systemic examination:

CVS: S1,S2 heard ,no murmurs

RS:

 Grade 2 dyspnoea,expiratory wheeze is present

Patient examined in sitting position

Inspection:-

oral cavity- Normal ,nose- normal ,pharynx-normal 

Shape of chest - funnel chest(Pectus excavation)

Chest movements : bilaterally symmetrically reduced

Trachea is central in position.

Palpation:-

All inspiratory findings are confirmed

Trachea central in position

Apical impulse in left 5th ICS, 

Chest movements bilaterally symmetrical 

Auscultation:-

BAE+,  NVBS

Abdomen:

On inspection:

Abdominal distention present

Skin over the abdomen is shiny 

Dilated vessels over the abdomen were seen 

Umbilical hernia is present (everted umbilicus)

Palpation:

Fluid thrill is absent but there is shifting of dullness

No tenderness and no palpable mass

Bowel sounds are heard

Liver and spleen are not palpable

 CNS:

No focal neurological deficits

provisional diagnosis:

ASCITES 

INVESTIGATION :

SAAG: 

Serum albumin : 2.1 g/dl 

Ascitic albumin : 0.22 g/dl

SAAG: 1.79 g/dl

Ascitic fluid protein sugar : 

Sugar -166 

Protein -2.5 

Ascitic fluid amylase :20.3

Ascitic fluid for LDH : 150 

TREATMENT:

-Inj.lasix 40mg/kg/BD

-Nebduolin 8th hrly

   Budicon 12th hrly

-Monitor vitals

-Tab.Azithromycin 500mg po/OD *3days

-Tab.Montek - hc po/OD *3days