1801006001- Short case

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 This is an online E log to discuss our patients de-identified health data shared after taking his/her/guardians signed informed consent.


Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evidence based inputs.


This E log book also reflects my patients-centered online learning portfolio and your valuable inputs on the comment box is welcome.

Chief complaints:


A 55 YEAR OLD MALE CAME WITH C/O 


ABDOMINAL DISTENTION SINCE 1 MONTH


DECREASED APPETITE SINCE 20 DAYS


FEVER SINCE 10 DAYS


History of present illness:

PATIENT WAS APPARENTLY ASYMPTOMATIC 1 MONTH BACK, THEN DEVELOPED ABDOMINAL DISTENTION WHICH IS INSIDIOUS IN ONSET AND GRADUALLY PROGRESSIVE. 


FEVER SINCE 10 DAYS WHICH IS OF HIGH GRADE, ASSOCIATED WITH CHILLS AND RIGORS, RAISED DURING EVENING AND NIGHT AND RELIEVED ON MEDICATION. 


HE ALSO HAD DECREASED APPETITE SINCE 20 DAYS


H/O BLACK COLOURED STOOLS FROM 10 DAYS


NO H/O PAIN ABDOMEN


NO H/O VOMITING


NO H/O LOOSE MOTIONS/CONSTIPATION


NO H/O BURNING MICTURITION


NO H/O HEMOPTYSIS 



PAST HISTORY:


N/K/C/O HTN/DM/TB/CAD/CVA/THYROID DISORDER/EPILEPSY


PERSONAL HISTORY:


DIET- MIXED


APPETITE- DECREASED


SLEEP- ADEQUATE


BOWEL AND BLADDER MOVEMENTS- REGULAR


ADDICTIONS- 


HE IS A CHRONIC ALCOHOLIC SINCE 30 YEARS( 2 QUARTERS/DAY). STOPPED SINCE 20 DAYS. 


HE IS ALSO A CHRONIC SMOKER SINCE 30 YEARS( 9 BEEDI/DAY) 


ON EXAMINATION:


PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE


PALLOR- ABSENT


ICTERUS- ABSENT


CYANOSIS- ABSENT


CLUBBING- ABSENT


LYMPHADENOPATHY- ABSENT


EDEMA- ABSENT


VITALS :


AT THE TIME OF ADMISSION :

TEMP. : 97.2

PR : 88 BPM

RR : 18 CPM

BP : 100/60 MM HG

SpO2 : 98%

GRBS:108 GM/DL





WEIGHT -49.4KGS(6/7/23)--- 49KGS(7/3/23) --48.6KGS(8/3/23) ---47. 6KGS(9/3/23) ---47. 58 KGS(10/3/23) 

ABDOMINAL GIRTH- 77.8CMS(6/3/23)---77.5CMS(7/3/23)---77 CMS(8/3/23)---73CMS(9/3/23) --78. 5CMS(10/3/23) 


ON SYSTEMIC EXAMINATION:


CVS : S1, S2 HEARD

RS : BAE PRESENT

        DECREASED BREATH SOUNDS IN LEFT IAA

        

P/A : TENDERNESS PRESENT IN EPIGASTRIC AND UMBLICAL REGIONS




CNS : HMF INTACT


INVESTIGATIONS:


ON 28/2/23

SERUM ELECTROLYTES

Sodium132

 potassium 4.0

chloride 96


Xray chest



On 6/3/23

HEMOGRAM

Monocytes 19%

Pcv 39.5 vol%

Mch 35 pg

Rbc count 3.71 millions/cumm


LFT

Total bilirubin 1.14mg/dl

 Direct bilirubin 0.33mg/dl

SGOT 47IU/L

Albumin 2.75gm/dl


RFT 

Chloride 92 meq/l


ASCITIC TAP IS DONE ON 6/3/23- 

ASCITIC TAP OF 450ML WAS DONE














ADA 

100.5 



MANTOUX TEST:DONE ON 8/3/23

BEFORE TEST


Day 0

Day 1






Day 2


Day 3

PROVISIONAL DIAGNOSIS:

ASCITIS UNDER EVALUATION(LOW SAAG HIGH PROTEIN ) SECONDARY TO
?CHRONIC LIVER DISEASE TO RULE OUT SPONTANEOUS BACTERIAL PERITONITIS 
?TB PERITONITIS 
LEFT PLUERAL EFFUSION

TREATMENT:
1) SALT RESTRICTION<2GM/DAY
2) FLUID RESTRICTION<1.2LIT/DAY
3) INJ CEFTOXIME 1GM IV/BD
4) INJ PAN 40MG IV/BD
5) INJ LACILACTONE20/25 PO/OD@9AM
6) SYP LACTULOSE 10ML PO/BD
7) TAB DOLO 650MG PO/TID
8) STRICT INPUT /OUTPUT CHARTING

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