45 year old male with Alcoholic liver disease

This is online E log book to discuss our patient's deidentified health data shared after taking his/her guardian signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve the patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient centered online learning portfolio and your valuble inputs on the comment box is welcome.

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.

Unit 1 

AMC bed 5

DOA:29/5/23

45 year old male ,lorry driver by occupation,resident of Nalgonda came to the opd with chief complaints of 

Abdominal distension since 5 days 

B/L swelling of lower limbs since 15 days

HOPI :he was apparently asymptomatic 15 days back then he developed swelling of both lower limbs (extending up to knee ,pitting type)insidious in onset ,gradually progressive, no aggravating and relieving factors .

Abdominal distension since 5 days ,insidious in onset ,gradually progressive,no aggravating and relieving factors 

Associated with bloating ,SOB and vomitings 

No h/o chest pain ,orthopnea ,PND,palpitations 

No h/o deceased urine output,burning micturition ,fever 

Past history:

K/c/o DM since 5 years on tab.metformin Po/BD

Not a k/c/o HTN,TB,BA,epilepsy,CAD,CVD

Personal history:

Diet :mixed 

Appetite:decreased 

Bowel and bladder:regular 

Sleep :adequate 

Addictions:chronic alocoholic since 10years

No known allergies 

Family history;insignificant 

General examination :

Pt is c,c,c .well oriented to time ,place, person

He is moderately built and moderately nourished

PALLOR-present

ICTERUS:present 

CLUBBING-absent

LYMPHADENOPATHY-absent

EDEMA-present 

VITALS;

TEMP:afebrile

PR:118bpm

RR:22cpm

BP:130/80 mm Hg 

Spo2:95%@RA

Local examination; 

Inspection;

Shape of abdomen;  distended

Position of umbilicus: central and inverted

No scars and sinuses are present

All quadrants are moving equally with respiration

Palpation:

No tenderness

No hepatomegaly 

Percussion:

No fluid thrill and shifting dullness

Auscultation: 

Bowel sounds are heard 

Systemic examination;

RS: BAE+,NVBS

CVS: S1,S2 HEARD

CNS; INTACT

Investigations:

Hemogram:

ECG:

2decho:

USG ABDOMEN:

CXR:

Treatment:

Inj.pan 40mg IV/OD 

Inj.thiamine 200mg in 100ml Ns /IV /TID

Inj.zofer 4mg/IV/TID

Inj.lasix 20mg IV/OD 

65 year old female with B/L pedal edema

This is online E log book to discuss our patient's deidentified health data shared after taking his/her guardian signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve the patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient centered online learning portfolio and your 

valuble inputs on the comment box is welcome.

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.

Unit 1 

DOA :27/523

A 65 yr old female ,resident of suryapet came to the opd with chief complaints

vomitings since 3 months 

swelling of both lower limbs since 1month.

HOPI:- Patient was apparently asymptomatic 3 months back. She then had vomitings (2-3 episodes/day) -on and off since 3 months

Vomitings - watery, non-projectile, non-bilious with food particles as contents and non blood stained.; Heart burn occasionally. Vomitings aggravating on after taking food .

-no c/o pain abdomen, loose stools.

C/o constipation - passes daily -hard stools or passes every alternate day

c/o swelling of bilateral lower limbs -pitting type, extending above ankle and not extending upto the knee. aggrevated on walking and relieved (incompletely) on lying down.

C/o Decreased urine output

 no h/o burning micturition, no involuntary micturition , Pt is unable to hold the urine during urge to micturition.

c/o SOB - after eating food, and after walking (Grade-II)

no c/o chest pain, palpitations, Orthopnea, PND.

c/o LBA-radiating to B/L lower limbs, no tingling sensation. c/o tingling of hands and feet.

Past history:

K/c/o Hypertension  7-years on medication.

(T. Amlodipine 5mg OD)..

Not a k/c/o TB, Epilepsy, Asthma, CVA, CAD,

Thyroid disorders.

personal history-

diet: mixed

appettite:normal

bowel and bladder: decreased urine output

sleep: adequate

no addictions

general examination:

patient is conscious,coherent, cooperative 

well oriented to time, place,person

moderatly built and nourished

vitals-

Temp: afebrile

PR :80bpm

BP :110/70 mmhg

RR :18cpm

GRBS :111mg/dl

systemic examination-

CVS:s1s2 heard,no murmurs

RS:BAE+,nvbs heard

CNS:nfnd,hmf intact

P/A:soft,non tender,no organomegaly

Investigations 

HEMOGRAM :

RBS:

RFT:

LFT:

ECG:

2D ECHO:

Moderate AR, MILD MR,MILD TR /PAH

NO RWMA,NO AS/MS SCLEROTIC AV

GOOD LV SYSTOLIC FUNCTION

DIASTOLIC DYSFUNCTION,NO PE

USG findings:

1)E/o multiple hypoechoic foci noted in gall bladder

Largest  measuring 7mm.

2)E/o 22*17mm exophytic cyst noted in upper pole of left kidney

Impression:

Cholelithiasis

Left renal cortical cyst

B/l raised echogenesity of kidneys 

CXR:

Treatment:

1.T.ONDANSETRON 4MG PO /OD

@8AM

2.T.PAN 40 MG PO /OD @8AM

3.T.PREGABALIN M 75MG PO /OD @2PM

4.T.BEPLEX FORTE PO /OD@8PM

5.SYP CREMAFFIN 10ML PO /HS

65yr old female with APD and Ckd stage 3B

This is online E log book to discuss our patient's deidentified health data shared after taking his/her guardian signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve the patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient centered online learning portfolio and your valuble inputs on the comment box is welcome.

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.

Unit -1 

Ward case 

DOA:15/5/23

65yr old female ,home maker ,residence of Nalgonda came with c/o abdominal distension and bloating since 4 days

HOPI: she was apparently asymptomatic 10 days ago then she developed fever ,insidious in onset,low grade ,intermittent type ,not associated with chills and Rigors ,no aggravating factors,relieving on medication,associated with body pains.

No h/o burning micturition,headache,cold and cough 

C/o vomitings in these 10 days ,5-6 episode(presently had 1 episode ,with food particles as content ,non projectile ,non bilious ,non blood stained 

C/o burning sensation in oral cavity since 10days(becoz of which she is unable to eat) ,no h/o dysphagia,loss of appetite and weight loss 

No h/o pain abdomen ,constipation or loose stools 

No h/o sob,chest pain ,pedal edema and palpitations and decreased urine output 

Now since 4 days c/o abdominal distension with bloating and belching 

Associated with regurgitation of food ,aggravating on lying down after taking food and no relieving factors 

Past history:

K/c/o DM2 since 6 yrs on regular medication tab.vidagliptin 50mg+metformin 500mg Po/BD

HTN since 6 years on tab telma-H (40-12.5)po/OD

General examination: 

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

Vitals :

Temp :afebrile 

PR:80bpm

RR:16cpm

Grbs:138mg/dl

No pallor ,icterus,clubbing ,cyanosis ,lymphadenopathy,oedema 

Systemic examination:

CVS:s1,s2 heard ,no murmurs

RS:BAE+,NVBS +

P/A: distended ,umbilicus :inverted 

Non tender ,no organomegaly 

No shifting dullness and fluid thrill 

Bowel sounds +

Gastro opinion taken for endoscopy:

Impression:Atrophic fundal gastritis 

opthal opinion taken I/v/o retinal changes for DM AND HTN :

Impression: on fundus examination of eye no changes of Hypertesion and diabetic retinopathy noted .

Nephrology opinion taken I/v/o deranged RFT(BU:45mg/dl and serum creatinine:1.7mg/dl)

Advised:

1.W/H tab.telma -H 

2.Consider tab.cinod 10mg Po/OD

3.Consider Inj.HAI sc/TID ,

If patient is uncooperative continue same diabetic medication.

Provisional diagnosis :

APD-Acid peptic disease

Investigations:

Hemogram:

RBS:

Blood urea:

Serum creatinine:

Serum electrolytes:

LFT 

HbA1C:6.8%

CUE:

Appearance :clear 

Albumin:+

Sugar :nil

Pus and epithelial cells:2-3 

RBC:Nil

Serology:negative 

ECG:

CXR:

2D echo:

FINAL DIAGNOSIS:

ACID PEPTIC disease- atrophic  gastritis with k/c/o HTN and DM since 6years

CKD:stage 3B

Treatment given :

1)Tab.RAZO -D 40mg Po/OD before breakfast 

2)Syp.sucrafyl-o Po/TID 15mins before food

3)Tab.CINOD 10mg Po/OD 

4)Tab.vidagliptin 5omg+metformin 500mg Po/BD

5)ZYTEE gel LA/TID

Advice at discharge:

1.Tab.RAZO-D 40mg Po/OD before breakfast 

2.Tab.CINOD 10mg Po/OD 

3.Tab.vidagliptin 5omg+metformin 500mg Po/BD

4.ZYTEE gel LA/TID

Follow up: 

Review to general medicine opd after one week with RFT report 

74year old female with abdominal distension and pedal oedema

This is online E log book to discuss our patient's deidentified health data shared after taking his/her guardian signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve the patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient centered online learning portfolio and your valuble inputs on the comment box is welcome.

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.

AMC CUBLICLE -BED 1

DOA: 11/5/23

A 74 year old female ,resident of nkp , came to the opd with chief complaints of 

Abdominal distension since 3 months 

Swelling of both lower limbs since 2 months

HOPI:

She was apparently asymptomatic 3 months ago then she developed abdominal distension,insidious in onset ,gradually progressive,aggravating on taking food ,relieving on taking mediation.

Then later she developed pedal oedema(pitting type ),insidious onset ,gradually progressive from ankle to above knee ,no aggravating factors and relieving on medication (as given by local RMP )

No h/o SOB,orthopnea,PND and decreased urine output 

No h/o abdominal pain ,constipation ,cough 

No h/o easy fatigability ,palpitations 

H/o low grade Fever +(on and off)

H/o burning micturition+

H/o weight loss is present(around 4-5 kg) since 6 months 

Past history:

K/c/o HTN and DM since 10 years ( on regular medication TEMLA-40 and METFORMIN 500mg)

H/o CVA  10-12 years ago

No h/o thyroid,TB,BA,Epilepsy 

Personal history:

Diet:mixed 

Appetite:decreased 

Bowel and bladder-regular 

Sleep -adequate

No addictions 

Family history:not significant 

General examination:

She is conscious, coherent and cooperative 

Well oriented to time ,place and person 

Vitals :

Temp: Afebrile

Bp:110/80mmofhg

PR:82bpm

RR:16cpm

Pallor :+

 Pedal edema +(bilateral pitting type ,up to ankle)

No icterus ,clubbing,cynosis,lymphadenopathy 

Local examination; 

Inspection;

Shape of abdomen;  distended

Position of umbilicus: central and inverted

No scars and sinuses are present

All quadrants are moving equally with respiration

Palpation:

No tenderness

Mild hepatomegaly is present

Percussion:

Fluid thrill present 

Auscultation:

Bowel sounds heard 

 

Systemic examination:

RS:BAE+,NVBS heard

CVS:s1,s2heard ,no murmurs

CNS:NO FND 

Provisional diagnosis: ASCITIS under evaluation 

Investigatons:

Diagnostic Ascitic tap :

 Serology :NR

Usg abdomen:

CXR:

ECG:

2decho:

12/5/23:

Fbs-109

RFT:

Ur-20

Cr-1.3

Uricacid-7.4

Ca-9.9

Po4 -2.6

Na+-140

K+-3.9

Cl-103

Hemogram:

Hb-7.4%

Tc-5,900

Plt-1.94

Pcv-25

Mcv-74.6

Mch-22

Rdw-cv: 32

Rbc-3.35

Portal Doppler:

USG abdomen :

Final diagnosis:

CHRONIC LIVER DISEASE with PORTAL HYPERTENSION (CIRRHOSIS)

Treatment:

1.Inj.lasix 40mg /IV/BD

2.Inj.optineuron 1amp/IM/OD

3.T.metformin 500mg Po/OD

4.Tab.Telma -40mg Po/OD