A 46 YR OLD MALE

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:
Patient came to OPD 7 days ago With chief complaint of 
Fever on and off episodes since 12 days
Loss of appetite since 12 days
Pedal edema since 7 days
Shortness of breath since 7 days
Jaundice since 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, decreased urine output. 

-No bowel and bladder irregularities. 

-No Head ache, Giddiness, Confusion. 


HISTORY OF PAST ILLNESS:
-K/C/O: Hypertension since 3yrs on unknown medication
-Not K/C/O: DM,TB, CAD, Asthama, Epilepsy.

FAMILY HISTORY:not significant

PERSONAL HISTORY:
Diet: mixed
Appetite: Decreased since 12 days 
Sleep: Adequate
Bowel and bladder: Regular
Addictions: Alcoholic ( 90ml) since 25 years
Tobacco chewing Since 5 yrs

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:
Abdomen:
-Shape of abdomen: Scaphoid 
-Tenderness: No
-Umbilicus: inverted 
-Dilated veins: No
-Free fluid: No
-Liver : palpable
-Spleen: not palpable
- Bowel sounds: Heard

Respiratory system :

-Inspection: Chest is moving bilaterally symmetrical. No pulsations.
-Palpation: Trachea is central in postion.
-Percussion: Resonant sounds
-Auscultation: Breath sounds are vescicular. 

CNS:

-Patient is conscious, coherent and cooperative.
-Speech is normal.
-Cranial nerves: intact

CVS:

-S1, S2 are heard.
-No murmurs.


Provisional diagnosis:
- Chronic liver disease


CLINICAL IMAGES:



INVESTIGATION:
-Hemogram:
-Blood grouping & RH type:
-Clotting time:
-Serum Creatinine:
-Blood Sugar:
-Ultrasound:


-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

-FINAL DIAGNOSIS:
.decompensated liver failure

. Moderate anemia

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