1801006136 - LONG 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 55 Yr old male resident of Narketpally, Nalgonda dist, Mechanic by occupation presented with the chief complaints of:

Abdominal Distention since 1 month
Decreased appetite since 20 days

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 1 month, then he developed abdominal distention, which was insidious in onset and gradual in progression.

History of decreased appetite since 20 days

History of black colored stools since 10 days

No History of fever, shortness of breath, cough

No History of Pain Abdomen

No History of Vomiting

No History of Diarrhea or Constipation

No History of Burning Micturation

No History of Hemoptysis

PAST HISTORY

Not a known case of Diabetes, Hypertension, Tuberculosis, Asthma, Thyroid Disorders, Epilepsy

PERSONAL HISTORY

Appetite: decreased

Diet: Mixed

Sleep: Adequate

Bowel and Bladder: Regular

Addictions: history of alcohol intake for 30 years [2 quarters/day], stopped since 20 days.

DAILY ROUTINE

He works as a mechanic, in a bike shop in Narketpally. He goes to his work on his bike at 9 in the morning and comes back home around 8 in the evening.

Since the past 30 years he has been consuming 180 - 200 ml of whiskey on a daily basis

30 years ago- started drinking alcohol

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3 years ago- admitted in a hospital with the similar complaints, got treated and discharged after 5 days

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Since 20 days, he couldn't cope up the work stress,consuming alcohol continuously, skipping food and not going to home

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Developed abdominal distention, and decreased appetite

FAMILY HISTORY

No history of similar complaints in the family.

TREATMENT HISTORY

Nil

GENERAL EXAMINATION:

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

Adequately built and Adequately nourished

Pallor - Absent

Icterus - Absent

Clubbing - Absent

Cyanosis - Absent

Lymphadenopathy -Absent

Pedal Edema - Absent

Vitals :

Temperature - 97.2 F

Pulse Rate - 88 beats per minute , Regular Rhythm, Normal In volume, No Radio-Radial or Radio-Femoral Delay

Blood Pressure - 100/60 mmHg measured in the left upper limb, in sitting position.

Respiratory Rate - 18 breaths per minute and regular

SpO2 - 98%

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 - Normal

Skin - No scars, sinuses, scratch marks, striae, no dilated veins, hernial orifices free

External genitalia - normal

Palpation -

No local rise in temperature,

Tenderness in epigastric and Umbilical Regions

Liver not palpable

Spleen not palpable

Kidneys are not palpable

Abdominal Girth - 78.5 cm

Xiphisternum - Umbilicus Distance - 19 cm

Umbilicus - Pubic Symphysis Distance - 13 cm

Spiro-Umbillical Distance - 26 cm on both sides

Percussion -

Shifting Dullness - Present

Liver span - Normal

Spleen Percussion - Normal

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

Percussion - Dull Note heard

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 kyphoscoliosis

No Winging of scapula

No Scars, sinuses, Dilated Veins

All areas move equally and symmetrically with respiration

Palpation -

Trachea is Midline

No tenderness, no local rise in temperature

Tactile Vocal Fremitus - Present in all 9 areas

Percussion -

Percussion Right                   Left
Supra clavicular:    resonant      resonant
Infra clavicular:         resonant      resonant
Mammary:    resonant     resonant
Axillary: resonant     resonant
Infra axillary: resonant     resonant
Supra scapular: resonant            resonant
Infra scapular: resonant     resonant
Inter scapular: resonant     resonant

Auscultation:              Right.                   Left

Supra clavicular:.       NVBS                NVBS
Infra clavicular:          NVBS                NVBS
Mammary:    NVBS NVBS
Axillary:    NVBS               NVBS
Infra axillary: NVBS      NVBS
Supra scapular:   NVBS NVBS
Infra scapular: NVBS               NVBS
Inter scapular: NVBS               NVBS

No added sounds

Vocal Resonance in all 9 areas

CENTRAL NERVOUS SYSTEM EXAMINATION

All Higher Mental Functions are intact

No Gait Abnormalities

No Bladder Abnormalities

Neck Rigidity Absent

PROVISIONAL DIAGNOSIS: Ascites secondary to chronic liver disease

INVESTIGATIONS: