GM case

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. 

Case :

A CASE OF CHRONIC LIVER DISEASE SECONDARY TO  ALCOHOLISM

A 43 year old male laborer by occupation presented with chief complaints of  pedal edema since 30 days, abdominal distension since 15 days.

HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic 30  days back, had history of  onset of swelling in the bilateral lower limbs, insidious, gradually progressive bilaterally up to the knee, pitting type, tender since 30 days, abdominal distension-progressive since 15 days, and not associated with facial puffiness, fatigue. 

No h/o of fever, pain abdomen, nausea, vomiting, SOB, palpitations.

HISTORY OF PAST ILLNESS:

No h/o of similar complaints in the past

K/C/O DM II since 5 years(on medication for 2 years, later stopped) 

N/K/C/O Epilepsy, Hypertension, TB

PERSONAL HISTORY

Mixed diet

Appetite normal

Sleep adequate

Bowel and Bladder movements regular

Addiction- Consumption of liquor since 18  years (180 ml)

Tobacco chewing:1-2/day since 15 years

FAMILY  HISTORY:

Not significant

DRUG HISTORY:


On medication for DM II since one month


No known allergies


GENERAL EXAMINATION:


Patient is conscious, coherent and cooperative


Moderately built and Moderately nourished


No Pallor


No Cyanosis


No Clubbing


No Icterus


No Generalized lymphadenopathy


Pedal edema-Bilateral, pitting type up to the knee


VITALS


Temperature: Afebrile


PR: 74 bpm


RR: 16 cpm


BP: 110/60 mm of Hg


SPO2: 98%


SYSTEMIC EXAMINATION:


CARDIOVASCULAR SYSTEM:


S1, S2 heard


No murmurs


RESPIRATORY SYSTEM:


BAE+


NVBS heard


CENTRAL NERVOUS SYSTEM:


Intact


No focal defect


No abnormality detected


ABDOMEN:


Distended abdomen


Scar is present in the centre


Umbilicus everted


Hernial orifices normal


Visible veins present


No visible pulsations


Palpitation:


Tenderness+


No local rise in temperature


Inspectory findings are confiirmed


No palpable mass


Liver, spleen not palpable


Free fluid present


Fluid thrills absent


Percussion:


Shifting dullness present


Auscultation:


Bowel sounds heard






Ascitic fluid is removed.


INVESTIGATIONS:

24/07/2021

HEMOGRAM:













FINAL DIAGNOSIS:



CHRONIC LIVER DISEASE (CLD) SECONDARY TO ALCOHOLISM.



TREATMENT:

24/07/2021

Rx:

INJ THIAMINE 1AMP IN 100ML NS/ IV/ OD

INJ OPTINEURON 1AMP IN 100ML NS/ IV/ OD

T. LASILACTONE (40/100) PO/OD

FLUID RESTRICTION <1L/DAY

T. RIFAXIMIN 550MG PO/OD

BP/PR/SPO2- MONITORING 2ND HRLY

GRBS - 6TH HRLY

ABDOMINAL GIRTH MEASUREMENT DAILY

SYP LACTULOSE 15 ML/ PO/OD

INJ HAI S/C ACC TO SLIDING SCALE


25/07/2021

No fresh complaints, stools passed

O/E, pt is c/c/c

afebrile

PR 74 bpm

BP 110/60 mm Hg

RR 16 cpm

SPO2 98% on room air

GRBS 151 mg/dl

CVS: S1 S2 heard

RS: NVBS +

P/A DISTENDED, FREE FLUID+, FLUID THRILL+

Rx:

FLUID RESTRICTION <1L/DAY

INJ THIAMINE 1AMP IN 100ML NS IV/BD

INJ OPTINEURON 1AMP IN 100ML NS IV/OD

T. LASILACTONE (40/100) PO/OD

T. RIFAXIMIN 550 MG PO/OD

SYP LACTULOSE 15 ML PO/OD TO PASS [STOOLS <= 2/DAY]

ABDOMEN GIRTH AND WEIGHT MONITORING -DAILY

BP/PR/TEMP/RR- 4TH HRLY

GRBS- 6TH HRLY

INFORM GRBS

INJ HAI S/C ACC TO SLIDING SCALE

8AM - 2PM - 8PM

26/07/2021

No fresh complaints, stools passed

Appetite improved


O/E, pt is c/c/c


Afebrile


PR - 72bpm


BP- 110/60


RR- 16 cpm


CVS: S1 S2 heard


CNS: No abnormality detected


RS: NVBS+


P/A: DISTENDED, FREE FLUID+, FLUID THRILLS ABSENT


Rx:


FLUID RESTRICTION<1L/ DAY


SALT RESTRICTION<2.4GR/ DAY


INJ THIAMINE 1 AMP IN 100 ML NS IV/TID


INJ OPTINEURON 1 AMP IN 100 ML NS IV/ OD


T. LASILACTONE(40/100) PO/OD


T. RIFAXIMIN 550 MG PO/BD


ABDOMINAL GIRTH MONITOR DAILY


WEIGHT MONITORING DAILY


BP/ PR/ TEMP/ Rx- 12 TH HRLY


GRBS- 6 TH HRLY


HAI S/C ACC TO SLIDING SCALE


8 AM - 3 PM  - 8PM


T. LIVOGEN 150 MG PO/OD


I/O CHARTING


27/07/2021


No fresh complaints, stools passed


Appetite improved


O/E pt is c/c/c


Afebrile


PR- 76 bpm


BP- 110/60 mm Hg


RR- 14 cpm


CVS: S1 S2 heard, no murmers


CNS: no abnormality detected


RS: NVBS +


P/A: DISTENDED, FREE FLUID +, FLUID THRILLS ABSENT


FLUID RESTRICTION < 1L/DAY


SALT RESTRICTION< 2.4 GR/ DAY


INJ THIAMINE 1 AMP IN 100 ML NS IV/TID


INJ OPTINEURON 1 AMP IN 100 ML NS IV/OD


T. LASILACTONE (40/100) PO/OD


T. RIFAXIMIN 550 MG PO/BD


ABDOMINAL GIRTH MONITOR DAILY 


WEIGHT MONITORING DAILY


BP/PR/TEMP/Rx -12 HRLY


GRBS - 6TH HRLY


HAI S/C ACC TO SLIDING SCALE


8AM - 3PM- 8PM


T. LIVOGEN 150 MG PO/OD


I/O CHARTING



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