CASE DISCUSSION 6 : 57 year ol man with jaundice ,pedal edema and abdominal distension
MOUNIKA KETHAVATHROLL NUMBER : 86
I have been given this case to solve in an attempt to understand the topic of patient clinical data analysis and to develop competency in reading & comprehending clinical data including history,clinical findings,investigations & come up with a diagnosis & treatment plan
My analysis of this case is found in the link below
Patient is chronic alcoholic since 40years daily 180ml of whisky taken and ocasionally toddy
Patient is non smoker,non diabetic and non hypertensive,no history of cad,cva tb, asthma
Pt is obese with gross abdominal obesity
Patient was apparently asymptomatic 3years ago then he noticed yellowish discoloration of eyes,bilateral pedal edema which is pitting type extending upto knees and abdominal distension
Then he went to local hospital (maxcure) and got lft done which showed mild derangement
Then he had bleeding gums and 2 days history of bilious vomitings ,no black stools
Patient got endoscopy done which didnt show any varices according to history (report not available)
Pedal edema decreased after medications but always mild edema and abdominal distension were present
Patient didnt stop alcohol and continued taking it everyday . One and half year later patient developed gradual increase in right lower limb swelling which is pitting type extending upto upper thigh with gross swelling and skin thickening were present , local rise of temperature present , he even had blebs (no history of trauma)which he punctured himself later it got infected so he was taken to thirumala hospital in 2018 where he was started on antibiotics ,piptaz and albumin infusions
Debridement was done
Reports in 2018:
Tb-2.20, DB-0.70,ALP-89,SGOT-22 ,SGPT-36
HB-13.7 ,TLC-4,800,PLT -4.8 Lakhs
S.creatinine -0.9,Na -138,K-3.9,Cl-101
Usg abdomen:
Moderate hepatosplenomegaly
Cholelithiasis(largest showing 6mm)
Small right renal calculus
Liver enlarged with coarse echotexture and nodular contour
2decho:normal
But swelling and skin thickening remained same
Endoscopy was done 3yrs ago and 1 and half year back which was normal again according to his daughter
No history of fever, pain abdomen or vomitings were present
Since 1 months patient was complaining of abdominal distension and shortness of breath on lying down and exertion
Patient attenders were giving history of multiple self medications whenever patient developed fever or shortness of breath they used to take decadron injections, larigo tablets,monocef and pantop over 4 months intermittently
Inspite of swelling and ulcerations patient used to do his regular activities and used to see opd ,no history of loss of appetite and used to ride bike and ho to hospital and going to washroom on his own
Since 1 month patient daughter giving history of forgetfulness ,depression and fear of dying
Since 5 days patient developed sudden increase in swelling of left lower limb with blebs,ulceration and increased temperature so he came to our hospital on Saturday and got dressing done
Since 1 week patient was bedridden and has generalised weakness and complaints of black stools intermittently
23/9/2019 11/09 19/09 21/09
Hb- 12.4 5.1 4.8 3.6
Tlc - 4,600 8,800 9,400 10,600
Plt - 80,000 90,000 85,000 1 lakh
Esr on 11/09 - 90mm/hr
11/09 s.creat-1.2 (outside hospital)
Urea-39
LFT ON 11/09 (OUTSIDE HOSPITAL)
TB-5 , DB-2.3 ,ALP-102 ,SGOT -55 ,
SGPT -43 , Alb-4.3
19/09 (our hospital report)
TB-3.6 , DB -2.84 ,SGOT-36 ,SGPT-29
ALP-224 , ALB-1.6
19/09 :
PT -20sec
INR -1.4
APTT-38sec
SEROLOGY NEGATIVE
O/E : patient is conscious,coherent ,cooperative
Obese ,pallor present
Spo2 -96% on room air ,
CVS -S1S2 heard no murmers
RS-decreased air entry and bilateral fine crepitations are present in IAA,ISA,MA
P/A- grossly distended with flat umbilicus
TB -2.75 ,DB- 2.43,ALP-213 ,ALB-1.4
SGOT-31 ,SGPT -26
Retic count - 1
PT - 35
INR - 2.59
APTT - more than 1 min
Urea - 77 , creat-1.1 ,Na-129, K -4.4 ,Cl-98
1. Air or water bed
2. Fluid restriction <1.5litres/day
Salt restriction <2.4gms/day
3. Inj augmentin 1.2gm IV/BD
4. Inj pan 40 mg IV/OD
5. Inj zofer 4mg IV/BD
6. Tab lasilactone (20/50)mg BD
If SBP <90mmhg -avoid
7. Inj vit k 10mg IM/ STAT
8. Syp lactulose 15ml/PO/BD
9. Tab udiliv 300mg/PO/BD
10.syp hepameiz 15 ml/PO/OD
11.IVF 1 NS slowly at 30ml/hr
12. Inj thiamine 100mg in 100mlNS /IV/TID
13.strict BP/PR/TEMP/Spo2 CHARTING HOURLY
14.strict I/O charting
15.GRBS 6th hourly
16.protein x powder in glass of milk TID
17. 2FFP and 1PRBC transfusion
Comments
Post a Comment