1801006180 SHORT CASE

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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 diagnosis and treatment plan.

CHIEF COMPLAINTS: 

A 40 Yr old male resident of Krishnapuram, Nalgonda dist, field assistant by occupation presented with the chief complaints of:

      .pain abdomen since 6 days

     . nausea and vomiting since 6 days 

     .abdominal distention since 5 days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 6 days ago, then he developed pain in abdomen of epigastric region which is severe, squeezing type, constant, radiating to the back and aggravated on doing any activity and relieved on sitting and bending forward.

He developed nausea and vomiting which was 10-15 episodes which was non bilious, non projectile and food as content ,and then he developed abdominal distention 5 days ago which is sudden onset, gradually progressive to current state.

no history of decreased urine output, facial puffiness,edema

no history of fever, shortness of breath, cough. 

PAST HISTORY :

   . history of diabetes since 5 years

    .history of hypertension since 5 years

  .no history of asthma,TB,epilepsy and thyroid        disorders.

     

PERSONAL HISTORY:

   Appetite: decreased

   Diet: mixed

   Sleep: adequate 

   Bowel and Bladder movements : regular 

   Addictions: history of alcohol intake for 5 years

 

 FAMILY HISTORY: 

  History of diabetes to patient's mother since 14 years

  History of diabetes to patient's father since 15 years 

TREATMENT HISTORY:

 metformin plus glimiperide

telmisartan 40 mg. 

GENERAL EXAMINATION:

Patient is conscious, coherent, cooperative and well oriented to time,place and person  

Moderately built and moderately nourished

 

     Pallor - Absent

     Icterus -present

     Clubbing - Absent

     Cyanosis - Absent

     Lymphadenopathy -Absent

    Pedal Edema - Absent 

Vitals : 

Temperature - 99 F

Pulse Rate - 80 beats per minute ,  Regular Rhythm, Normal In volume, No Radio-Radial or Radio-Femoral Delay

Blood Pressure - 130/90 mmHg measured in the left upper limb, in sitting position.

Respiratory Rate - 13 breaths per minute and regular

 

SYSTEMIC EXAMINATION:

Patient examined in a well lit room, after taking informed consent.

GASTROINTESTINAL SYSTEM EXAMINATION

Oral Cavity: Normal

Per Abdomen : 

 

Inspection - 

Shape - Uniformly Distended 

Umbilicus - displaced downwards

Skin -  No scars, sinuses, scratch marks, striae, no dilated veins, hernial orifices free, skin over the abdomen is smooth

External genitalia - normal. 

Palpation - 

 

No local rise in temperature, tenderness in epigastric area

Liver not palpable

Spleen not palpable

Kidneys are not palpable

Abdominal Girth - 84 cm

Xiphisternum - Umbilicus Distance - 21 cm

Umbilicus - Pubic Symphysis Distance - 15 cm

Spino-Umbilical Distance - 19 cm and equal on both sides

Percussion - 

Shifting Dullness - Present

Liver dullness at 5th intercoastal space along midclavicular line - Normal

Spleen Percussion - Normal

Tidal Percussion - Absent

Auscultation -

Bowel Sounds - Absent

No Bruit or Venous Hum

CARDIOVASCULAR SYSTEM EXAMINATION

Inspection - 

Chest Wall is Symmetrical

Precordial Bulge is not seen

No dilated veins, scars, sinuses

Apical impulse - Not Seen

Jugular Venous Pulse - Not Raised

 

Palpation - 

Apical Impulse - Felt at 5th Intercostal space in the mid clavicular line

No thrills, no dilated veins

 

 Auscultation - 

Mitral Area  -  First and Second Heart Sounds Heard, No other sounds are heard

Tricuspid Area -  First and Second Heart Sounds Heard, No other sounds are heard

Pulmonary Area - First and Second Heart Sounds Heard, No other sounds are heard

Aortic Area - First and Second Heart Sounds Heard, No other sounds are heard. 

RESPIRATORY SYSTEM EXAMINATION

Inspection - 

 

Chest is symmetrical

Trachea is midline

No retractions

No Scars, sinuses, Dilated Veins

All areas move equally and symmetrically with respiration

 

Palpation - 

 

Trachea is Midline

No tenderness, local rise in temperature

Tactile Vocal Fremitus - Present in all 9 areas

 

 

Percussion - resonant all over the chest

 

Auscultation - normal vesicular breath sounds heard all over the chest

No added sounds 

Vocal Resonance in all 9 areas- normal

CENTRAL NERVOUS SYSTEM EXAMINATION

All Higher Mental Functions are intact

No Gait Abnormalities

Signs of Meningial signs absent

Provisional diagnosis 

Ascites

Investigations. 

Complete blood picture

Hb 14.2 g/dl

Total count 14700

Neutrophils 90%

 Lymphocytes 5%

Eosinophils 2%

 monocytes 3 %

 basophils 0

Platelet count 2.5 lakhs per cubic mm

Smear normocytic normochromic with neutrophilic Leukocytosis. 

Liver function test

 total bilirubin 2.1 mg/dl

direct bilirubin 0.6mg/dl

 sgot 28iu/l

sgpt 17iu/l

 alkaline phosphate 113 

total protein 7.4 g/dl

albumin 4.1g/dl

 A /g ratio 1.2 

RBS 540 mg /dl

hbA1c 7.6%.

Ascitic fluid analysis  

cell count 50 cells 

Cytology negative for malignance cells

 sugar 98 mg/decilitre

 protein 5.1g/dl

 albumin 3.3 g/dl

amylase 1055 iu/l

ADA 16IU/L

 LDH 200IU/L

 gram stain negative

 AFB no growth 

culture no growth

 SAAG 0.8

 serum amylase 540iu/l

 serum lipase 186 iu/l

serum album 4.1 g/dl

Ascitic fluid albumin 3.3g/dl.

  

USG ABDOMEN :

mild to moderate ascites is seen

FINAL DIAGNOSIS:

Ascites secondary to Acute Pancreatitis

MANAGEMENT

 

NPO

IV Fluids - N/S 

Inj. PANTOP 40 mg IV BD

Inj. ZOFER 4 mg IV SOS

Inj, PIPTAZ 2.25 mg IV TID

Tab. AMLONG 20 mg PO OD

Tab.LASIX 40 mg BD

GRBS every 4th hourly

Inj TRAMADOL 1 amp IV+100 ml NS IV OD