1801006071-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.

 55 year old Female patient who is resident of Chityal came to OPD with 

CHIEF COMPLAINTS:

Fever since 13 days back

Pain in  Abdomen since 10 days back

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 3 months back then she developed itching over the right leg then after due to scratching she developed leg swelling upto ankle for which she went to local RMP doctor then he gave intramuscular injection at left buttock for which she develop swelling, eventually she developed pustule over the injection site and progressed to form ulcer.

History of fever since 13 days which is insidious in onset,low grade,intermittent associated with chills and rigor.Fever is associated with cough with sputum scanty in amount,non blood stained ,mucoid in nature.No histoty of loose stools,cold,Burning sensation.History of decreased urine output no history of dribbling of urine,urgency.

After 3 days,she developed pain in abdomen which is insidious in onset gradually progressive,the pain is localized to the upper abdomen, pricking type of pain, non radiating with no aggravating or relieving factors.she also developed Shortness of Breath which is  grade 3 which is not associated with Orthopnea and Paroxysmal nocturnal Dyspnea.No History of Vomiting,loose stools.

She was taken to local hospital.She was found to be having some kidney problem and given medication.

After that Shortness of breath is subsided but fever is intermittent and pain is not resolved.Pain became severe.She brought to our hospital for further evaluation.

On admissiom day there is history of Vomiting, 2 episodes ,watery in consistency with no food particles, non bilious, non blood stained.

PAST HISTORY:

She is hypertensive since 3 years and she is on regular medication.

No History of Diabetes,Asthma,Tuberculosis,Leprosy,Epilepsy.

PERSONAL HISTORY:

She is mother of 5 childern(3 females and 2 male).She lives with her husband.She wakes up at 6:30AM. At 8 she has breakfast which she usually she take rice and curry. She gets ready and goes to the local market to sell lemons.  She takes a lunchbox and has her lunch there which again consists of rice and curry. Around 5 PM  she comes back to her house. She does her daily chores.She has dinner at around 8PM and goes to bed at 9PM.

Diet:Mixed

Appetite:Reduced

Sleep: Reduced since 10 days.

Bowel movement:regular

Bladder movement:reduced since 10days

Addiction:she regularly take toddy every day since 10 years and every 3days she used to take alcohol 

FAMILY HISTORY:

No relevant Family history.

Fever chart:

GENERAL EXAMINATION:

Patient is conscious coherent and cooperative. Well oriented to time place and person. Moderately built and nourished. Pallor present.No Icterus, cyanosis, clubbing, lymphadenopathy.Mild edema present.

Ulcer:

VITALS:

Pulse - 74 beats per minute.

BP - 110/80 mm Hg

RR - 18 Cycles per minute

Temp- 98.3°C.

SYSTEMIC EXAMINATION:

ABDOMEN:

INSPECTION:

Shape is round,Generalized Distension is seen

Umbilicus is Inverted.

Equal symmetrical movements in all the quadrants with respiration.

Scar is visible.

No visible pulsations,peristalsis,visible swelling, dilated veins are seen.

PALPATION:

Tenderness is noted in Right hypochondrium region.No local rise of temperature,No Rigidity and Guarding is seen.

LIVER:

Enlarged, soft in consistency smooth surface,rounded edges, tender, non pulsatile

No spleenomegaly.

Abdominal girth :-106cm.

PERCUSSION:

Hepatomegaly : 

 liver span of 15 cms with 4 cms extending below the costal margin

Fluid thrill and shifting dullness absent

Tympanic note is present

ASCULTATION:

Bowel sounds heard.

No venous hum or bruit.

CVS:

Inspection:

Position of the trachea is central. 

Apical impulse is not observed. 

No other visible pulsations, dilated and engorged veins,sinuses. 

Palpation:

Apex beat was localised.

Position of trachea was central 

No parasternal heave , thrills, tender points. 

Auscultation: 

S1 and S2 were heard 

There were no added sounds / murmurs.

Respiratory system:

Trachea central

Bilateral air entry is present 

Normal vesicular breath sounds are heard. 

Resonant on percussion.

CNS:

Higher mental functions- 

Normal

Memory intact

Cranial nerves :intact

Sensory Examination:

Normal 

Motor Examination:

Normal tone in both limbs

Normal power in both limbs

Reflexes:

            Right              Left 

Biceps     2+                2+

Triceps    2+                2+

Knee        2+                2+

Ankle       2+                2+

INVESTIGATIONS:

17th march

Complete blood picture:

Haemoglobin:9.6 g%

Red blood cells:3.1 million/mm3

Pcv:29.6 vol%

Platelet count:6.6.lakhs/mm3

Total leucocyte count:15,600/mm3

Blood urea 60mg/dl

Sr creatinine 1.0 mg/dl

serum Na 133mmol/dl

Serum K 3.6mmol/dl

Serum Cl 99 mmol/dl

complete urine examination:

Color-pale yellow

Appearance- clear

Specific gravity-1.010

Sugar-nil

Albumin:Trace

Pus cells:2-4hpf

Epithelial cells-2-3/hpf.

16th March

Blood urea-70 mg/dl

Serum creatinine -1.1mg/dl

Serum sodium-132meq/dl

Serum potassium-3.2meq/dl

Serum chloride-98meq/lt

complete urine examination:

Color-pale yellow

Appearance- clear

Specific gravity-1.010

Sugar-nil

Albumin:Trace

pus cells:2-4hpf

15th march 

Serum creatinine :1.6mg/dl

14th march:

Total bilirubin:2.6 mg/dl

Direct bilirubin: 1.1 mg/dl

Indirect bilirubin:1.5mg/dl

Alkaline phosphatase:193IU

AST:37 IU

ALT:21 IU

Protein total: 7.0 g/dL

Albumin:4.3g/dl

Globulin:2.7 g/dl

Albumin and globulin ratio:1.6

Serum creatinine:2.1mg/dl

13th March:

Complete Blood picture:

Haemoglobin:11.7 g%

Red blood cells:3.81 million/mm3

Pcv:32.5 %

Platelet count:5.0 lakhs/mm3

Total leucocyte count:22,400 /mm3

Blood urea 58 mg/dl

Sr creatinine 1.9 mg/dl

serum Na 127 mmol/dl

Serum K 3.4 mmol/dl

Serum Cl 92 mmol/dl

Lipid profile:

Total cholesterol:218mg/dl

Triglycerides:240mg/dl

HDL cholestrol:54 mg/dl

LDL cholestrol:116mg/dl

VLDL Cholestrol:48mg/dl

ECG:

USG:

USG Abdomen:

Findings- 5 mm calculus noted in gall bladder with GB sludge

Impression- Cholelithiasis with GB sludge

Grade 2 fatty liver with hepatomegaly .

DIAGNOSIS:

Pain abdomen secondary to cholecytitis,Alcoholic liver disease.

TREATMENT:

Inj PAN 40 mg iv/ od

Inj PIPTAZ 2.25mg/iv/TID

Inj. METROGYL 500mg / iv/tid

 Inj zofer 4mg iv/sos

INJ NEOMOL 1gm iv/sos

T.PCM 650mg po/tid

T.CINOD 10mg po/od 

Iv fluids 1 unit NS, RL, DNS 100 ml/hr

Pneumatic compressor bed.