53 M WITH DECOMPENSATED ALCOHOLICLIVER DISEASE WITH PORTAL HYPERTENSION WITHTHROMBOCYTOPENIA
June 12,2023
Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those 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 valuable inputs on the comment box is welcome.”
I've 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 a diagnosis and treatment plan
CHIEF COMPLAINT
This is a case of a 53-year-old male, a Hotel owner and chief by occupation,
The patient presented to the hospital with chief complaints of
Swelling of both Legs since 20 days
Swelling of face since 7 days
Decrease intake of food since 20 days
HISTORY OF PRESENTING ILLNESS
The patient was apparently asymptomatic 20 days ago.
Then he developed Bilateral Pedal odema which is pitting type extending up to the knee, insidious in gradually progressive , since one week
Patient has decreased urine output since 10 days not associated with burning micturation
- yellowish discolouration of urine
- constipation since 15 days
No c/o - Chest pain, Palpitations , Shortness of breath ,Orthopnea, PND
No c/o - Fever , Vomitings , loose stools.
Not K/N/C- Hypertension, Epilepsy, Thyroid disorders.
K/C/O - Chronic Alcoholic since 20 yrs , every day consumption around 360 ml
Last consumption 1 week back.
PAST HISTORY
- Patient was diagnosed with Poliomyelitis of upper limb and lower limb of left side in his early childhood age .
- No past surgical history
FAMILY HISTORY
Patient was born to Congenious parents and was bought up in joint family house along with his other siblings. his father owns a farm lands which was divided among his father’s brother.
Patient was in good terms with his parents up to certain period of time.
Later than he has separated from then and use to live along with his wife parents in their house.after some years he moved out from his native place to another place along with his wife.
PERSONAL HISTORY
- Appetite - Decreased for the past 7 days.
- No Burning Micturation is present for the past 7 days
- Constipation for 3-4 days with every episode
- Sleep - adequate
- Diet - Non-Veg & Mixed (Veg) sometimes
- Chronic Alcoholic since 20 years
- No allergies
Marital status-married twice
Patient had married twice. With his first wife he has 2 sons 1 daughter .
due to miss understandings between both husband and wife they decided to separate and got separated and he got married to another women . but his parents were not happy with their separation and didn’t allow his 2nd wife to enter their home.
After all familial fight with his parents and his 1st wife, he decided to leave his home and moved into his 2nd wife home and he has 2 daughters with is 2nd wife to.
Due to this familial separation and fight among them he lost his father farm lands.
Which made him to suffer lot of financial trouble.
OCCUPATIONAL HISTORY
Previously was a farmer in his farm land which was given to him before his 2nd marriage later he moved from his 2nd wife place to another city and started his own Hotel .
He's an alcoholic addict since 20yrs who use drink weekly but gradually it has become daily habit, he's everyday consumption was about 360ml since few months
- Wakes up 6 am gets fresh up .
- 7am and goes to hotel and starts cooking
- 8am along with drinking alcohol and continues his work again he starts drinking 11:30am.
- 2pm - he takes lunch and sleeps till 5pm up get fresh up & start drinking 7pm .
- Eats dinner at 8 and sleeps around 9 to 10.
GENERAL EXAMINATION
Patient was conscious ,non-coherent , cooperative ,well built and nourished not so well oriented to time place & person at the time of presentation.
Pallor- present
Icterus-present
Cyanosis-absent
Clubbing-present
Lymphadenopathy-absent
Edema -present b/l pitting type .
VITALS
Temperature-97.6'f
Pulse rate -90bpm.
Bp-150/80mm hg
RR-17cpm
Spo2-99% .
grbs-110mg/
Abdomen examination
INSPECTION:-
Shape of abdomen -distended
Umbilicus-inverted.
No scars ,sinuses,straie
No visible pulsations & visible peristalsis.
Moments of all 4quadrants moving equally with respiration
Ecchymosis on Left shoulder
Percussion:-
Shifting dullness-+
No signs of fluid thrill.
CVS:-
S1,S2heard ,no murmurs.
CNS :-
Higher motor functions - intact
Cranial nerves - intact
Motor system:
Power : Rt-UL LL. Lt -UL LL
5/5 5/5. 5/5 5/5
Hand grip. 100%. 0%
Reflexes:
UL. LL
Biceps. 2+. +2
Triceps. 2+. +2
Supinator. 0 0
Knee 0 2+
ankle jerk cannot be seen due to pedal edema? Sensory system: intact
Cerebellar functions are normal
Respiratory examination:-
Trachea is central
Chest moments -normal
Bae-+
Investigation
09.06.2023 - 10.06.2023
11.06.2023
12.06.2023
13.06.2023
Ascitic Fluid
Volume-3ml
Colour-clear
Rbc-nil
Tc-50
Dc-100
Others nil
Esophagus : Grade -1 Esophageal varices (2 columns)
Stomach : Severe PHG ( portal hypertension gastropathy)
Duodenum: D1 D2 normal
Impression : Severe PHG with Grade -1 Esophageal varices
Comments
Post a Comment