INTERNAL ASSESSMENT ( PRACTICAL )

This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan

 SHORT CASE :

A 48 year old male, auto driver by occupation came to the opd with chief complaints of 

Abdominal distension since 20 days

Bilateral lower limb swelling since 15 days

Decreased urine output since 10 days

Breathlessness since 10 days

Blood in stools since 5 days

Loose stools since 4 days

HOPI : 

Patient ws apparently normal 20 days back.Then he developed abdominal distension which was insidious in onset and gradually progressed to present size. 

Bilateral pedal edema since 15 days which is pitting type and extended till the knee joint.

Decreased urine output since 10 days.

Shortness of breath since 10 days, insidious in onset, gradually progressed from grade 1 to grade 3 .SOB increased on exertion and relieved on taking rest.No orthopnea .No PND.

history of blood in stools since 5 days -- blood at the end of defecation. He had loose stools since 4 days,4-5 episodes per day. Watery stool, non mucoid , small quantity, associated with blood

No history of fever, vomiting,chest pain,giddiness, pain abdomen , No mass per rectum

PAST HISTORY : 

History of jaundice present :2 years back and 6 months back and was managed conservatively with medication.

K/c/o Hypertension since 10 years, initially was on T.TELMA 80 mg which was later reduced to T.TELMA 40 mg and now the patient is on T.AMLONG 5mg + ATENOLOL 50mg PO OD

N/k/c/o DM-2,TB,CAD,CVD

PERSONAL HISTORY :

Diet : Mixed

Appetite : Decreased since 20 days

Bowel and bladder movements : Decreased urine output 

Sleep : Adequate 

No allergies

He is alcoholic since 25 years initially 260 ml/day .stopped taking alcohol since 2 years( As he was said to have liver failure ) . But he took 2 months back along with his friends 

FAMILY HISTORY : No significant family history 

GENERAL EXAMINATION :

On Examination 

He is conscious, coherent and cooperative. 

Well oriented to time, place and person.             

Icterus - present ( Mild )

Bilateral pedal edema - present, pitting edema extending upto knees 

No pallor, Cyanosis, clubbing, lymphadenopathy 

            


Vitals ( on presentation)

Pulse - 76 beats per minute, regular in rhythm, normal in volume and character of vessel, no radio- radial delay, no radio - femoral delay. 

Blood pressure - 110/70 mm of hg, measured in the left arm in supine position

Respiratory rate - 20 cycles per minute

Temperature - afebrile 

Spo2 - 98% at room air

GRBS - 94 mg/dL  


Systemic Examination:

Per abdomen :

Inspection - abdomen distended 

                      Umbilicus is flat and central 

                       few Dialted venis visible

                      No visible scars or sinuses

                      No visible gastric peristalsis

                


 


     Palpation - No local rise of temperature

                     No tenderness

                    Organs couldn't be palpated ( Due to fluid )  

Examination video https://youtube.com/shorts/m2js7NhRJaM?feature=share 

Percussion - fluid thrill present 

Examination video :

https://youtube.com/shorts/dDb3byfckPY?feature=share

Auscultation - bowel sounds normal 

Respiratory System : bilateral air entry +

Cardiovascular System : S1, S2 heard , No murmurs 

Central Nervous system : Normal   

INVESTIGATIONS :

COMPLETE BLOOD PICTURE :-

Hb:- 11.1 gm/dl

TLC:- 9500 

Neutrophils :- 78%

Lymphocytes :- 12%

Monocytes :- 8%

Eosinophils:- 2%

PCV:-34 %

MCV:-96  fl

MCH:- 31.1 pg

MCHC:- 32.6 %

RBC:- 3.54 million/cumm

PLATELETS:- 2.27 lakhs /cu mm

Peripheral smear : Normocytic Normochromic 

COMPLETE URINE EXAMINATION:-

Pus cells- 3-4

Epithelial cells :- 2-3 

Albumin :- 1+

Sugars :- Nil

No RBC , No casts 

RFT :-

Urea:- 10 mg/dl

Creatinine:- 1.4 mg/dl 

Sodium:- 138 mEq/L

Potassium:- 3.5 mEq/L

Chloride :- 104 mEq/L 

LFT:-

Total Bilirubin :- 2.54 mg/dl

Direct Bilirubin:- 0.58 mg/dl

AST:- 44 IU/L

ALT:- 12 IU/L

Alkaline phosphatase:- 201 IU/L

Total proteins :- 5.5 gm/dl

Albumin :- 2.3  gm/dl

A/G ratio:- 0.56

Aptt : 37 sec 

PT : 18 sec 

INR : 1.3

Serology :- NEGATIVE 

USG ABDOMEN : 

Cirrhosis of liver 

Raised echogenicity of bilateral kidney 

Gross Ascitis 

Spleenomegaly 


2D ECHO:

Impression:-

EF:- 68% 

Mild LVH +

RVSP:- 35 mmhg 

TRIVIAL TR+/ AR+ , No MR

NO RWMA , NO AS/MS

Good LV Systolic Functions 

Diastolic Dysfunction + 

Mild Pericardial and pleural effusion + 

IVC : Non collapsing ( Size : 1.27 cms) 

ECG : 


Ascitic  tap done : About 800ml of fluid was taken

Ascitic fluid Analysis :

Ascitic sugar : 123 mg/dl 

Ascitic albumin : 0.55 

SAAG : 1.95 ( Serum albumin : 2.5 )

Protein : 1.2 

LDH : 38 IU/L

Amylase : 14 IU/L 

Diagnosis :

DECOMPENSATED CHRONIC LIVER DISEASE SECONDARY TO ALCOHOL 

BLOOD LOSS IN STOOL SECONDARY TO ? INTERNAL HAEMORRHOIDS or ? FISSURE IN ANO

?OESOPHAGEAL VARICES SECONDARY TO PORTAL HYPERTENSION 

Treatment :

Inj.THIAMINE 200mg in 100ml NS IV OD 

Tab.UDILIV 300mg PO BD 

Tab.ALDACTONE 50mg PO OD

Tab.SPOROLAC DS PO TID

ORS sachets - 2 sachets in 1 litre of water and 200ml after each episode 

Protein powder in a glass of milk

 Monitor vitals,input and output, Abdominal girth.

Day 2

Loose stools subsided

Abdominal girth 102cm -------99cm

Weight 70kgs -----69kgs

Psychiatry referal was done i/v/o alcohol dependence

Patient is psychoeducated and Tab.Pregabalin 75 mg is advised.

Surgery referral done i/v/o blood in stools

and the patient is diagnosed to have internal haemorrhoids secondary to portal hypertension,advised banding or sclerotherapy if bleed continues or if there is significant drop in haemoglobin.

Inj.THIAMINE 200mg in 100ml NS IV OD

 Tab.ALDACTONE 50mg PO OD

Tab.PREGABALIN M 75mg PO HS

Protein powder 2tbsp in a glass of milk

Monitor vitals,input and output, Abdominal girth.

Restriction of fluids <1.5lit/day 

Day 3 : 

Urea:- 32 mg/dl

Creatinine:- 1.2mg/dl 

Sodium:- 14 mEq/L

Potassium:- 3.7 mEq/L

Chloride :- 104 mEq/L 

LFT:-

Total Bilirubin :- 1.92 mg/dl

Direct Bilirubin:- 1.40 mg/dl

AST:- 38 IU/L

ALT:- 12 IU/L

Alkaline phosphatase:- 193 IU/L

Total proteins :- 6.5 gm/dl

Albumin :- 2.25 gm/dl

A/G ratio:- 0.53

Endoscopy was done and diagnosed to grade 4 oesophageal varices 

Therapeutic tap done : 500 ml was tapped 

Day 4 : 

Pt had hypotension so started on 

Inj Noradrenaline 4mg in 46ml NS @4ml/hr 

Was started and BP monitoring was done 

Final Diagnosis :

DECOMPENSATED CHRONIC LIVER DISEASE SECONDARY TO ALCOHOL AND ALCOHOL DEPENDENCE SYNDROME ( Currently not in withdrawal or hepatic encephalopathy )

BLOOD LOSS IN STOOL SECONDARY TO ? INTERNAL HAEMORRHOIDS 

GRADE 4 OESOPHAGEAL VARICES SECONDARY TO PORTAL HYPERTENSION 


              











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