46 year old male with chronic liver disease

​This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 


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 46 year old male who is resident of Bhongir and by occupation a Barber came to OPD on 11th of January at 4:10 pm.

CHIEF COMPLAINTS:
Fever on and off episodes:12 days

Loss of appetite:12 days

Pedal edema:7 days

Shortness of breath :7 days


HISTORY OF PRESENT ILLNESS:
-Patient was apparently asymptomatic 12 days back then he complained of fever which is low grade, intermittent, on and off episodes get relieved on medication. 

-Patient complained of B/L pedal edema present below the knees, pitting type, present since 7days which get aggravated on standing for long periods and slightly reduced on taking rest. 

-Shortness of breath present since 7 days which is grade 2(developing shortness of breath while walking to washroom). 

-Patient also complained of loss of appetite :12 days

-Patient also complained of abdominal tightness, bloating of abdomen. 

-No History of chest pain, chest tightness, palpitations. 

-No History of abdominal pain, vomitings, constipation, loose stools. 

-No History of burning micturition, decresaed urine output. 

-No bowel and bladder irregularities. 

-No Head ache, Giddiness, Confusion. 

HISTORY OF PAST ILLNESS:

-K/C/O: Hypertension: 3 years on unknown medication.
-Not K/C/O: DM,TB, CAD, Asthama, Epilepsy.

FAMILY HISTORY:not significant

PERSONAL HISTORY:

-Appetite:Normal(Decreased since 12 days) 

-Diet:Mixed

-Bowel and Bladder habits:Regular

-Addiction: patient consumes alcohol since 25 years (90ml)

-Tobacco chewing since 5 years. 

GENERAL EXAMINATION:
-Patient is conscious, coherent and cooperative.
-Well oriented to time, place and person.
Moderately built and well nourished.
-Temp:afebrile
-Pallor: yes
-Icterus: yes
-Cyanosis: no
-Clubbing of fingers: no
-Lymphadenopathy: no
-Pedal oedema: yes

VITALS:
-BP: 110/70mmHg 
-PR: 100bpm
-RR: 16 cpm
-SpO2: 98%

SYSTEMIC EXAMINATION:

CNS examination:

-Patient is conscious, coherent and cooperative.
-Speech is normal.
-NAD(no abnormality detected)

CVS examination:

-S1, S2 are heard.
-No murmurs.


Respiratory system examination:

-Bilateral air entry present.Normal vesicular breath sounds heard.Position of trachea central.


Abdomen:
Inspection:
Shape of Abdomen:Distended
Umbilicus:Everted
No Dilated veins, visible peristalsis, engorged veins, scars.
Palpation:
Liver : palpable 
Spleen: not palpable
Percussion:
Resonant note heard
Auscultation:
Bowel sounds heard. 

Provisional diagnosis:
- Chronic liver disease


CLINICAL IMAGES:






INVESTIGATION:
-Hemogram:11/1/23
13/1/23

18/1/23

-Clotting time:
-Serum Creatinine:
-Blood Sugar:


X-RAY 

-ECG:

-TREATMENT:
-Inj Monocef 1gm IV/BD
-Inj Neomol 1gm IV
-Syrup Lactulose 30ml PO/BD
-Inj Lasix 20mg IV/BD
-Inj Thiamine 100mg 
-Tab Rifagut 550mg
-Tab Udiliv 300mg
-Metadoxine
-FINAL DIAGNOSIS:
.Decompensated Chronic Liver Disease
. Moderate anemia



Comments

Post a Comment

Popular posts from this blog

A 26year old Patient came to casuality with shortness of breath

Image
  This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. A 26 year old male patient, resident of adauidulpally, Nalgonda district farmer by occupation came to our hospital with chief complaints of - 1. Shortness of breath 2. Loss of appetite 3. Low grade Fever  4. Pedel edema Date of admission :- 05/04/2022 History of present illness: - Patient was apparently normal 1week back , then he had one episode of low grade fever, Generalized body pains, burning micturtion but relieved with medication.Then developed pedal edema,initially till ankle Loss of appetite  4-5 days back associated with nausea and  4 days back one episode of vomiting  Non bilious and no food par
Read more

50 year old female with fever ,thrombocytopenia

Image
​ This is an online E-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. CASE PRESENTATION: A 50 year old female came to casualty  with c/o Fever since 7 days  HOPI : Patient was apparently asymptomatic 7 days back then she developed fever which is  of high grade,intermittent, not  associated with chills and increased during night.2 days later She went to a local hospital where she was diagnosed with typhoid.she was on medication. Her platelets count reduced and fever is not subsided.  She also complained of mild head ache since 4 days ,relieved on medication  No h/o nausea, vomiting  No h/o loose stools/constipation  No h/o pain abdomen No h/o Burning micturition  PAST
Read more

48 year old male with vomitings and pain in the abdomen

Image
This is an online E-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. CASE PRESENTATION: A 48 year old male came to casualty with c/o Vomiting since 1day Pain abdomen since 1 day HOPI: Patient was apparently asymptomatic 1 day back then he developed vomitings (20 episodes-non projectile, non bilious) He also had pain in the epigastric region which is non progressive,  non radiating.  No h/o fever/head ache No h/o cough/cold No h/o constipation/loose stools No h/o Burning micturition  No h/o bleeding manifestations  PAST HISTORY: Not a k/c/o DM/HTN/TB/ASHTMA/EPILEPSY/CAD  Personal History : Diet : mixed Appetite : Normal  Sleep : Adequate  Bowel movements : Normal  Bladd
Read more