A 41 year old female with chronic liver disease.
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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.
Patient is apparently asymptomatic 4months ago and she developed fever which is insidious in onset,low grade, intermittent,no diurnal variation not associated with chills and rigor.
Vomiting insidious in onset,non projectile, non bilious, less quantity,odorless,non blood stained,content is food.
Then she noticed yellowish discoloration of eyes, initially noticed in eye with high coloured urine and loss of appetite.
Not associated with pruritis,clay coloured stool.
For which she took herbal treatment for 1 week,after which there is no improvement .
Then she went to local hospital at miryalguda and tested positive for HbSAg she took treatment for 10 days and no improvement is observed
Then she went to Gandhi hospital and took treatment 1month 10days for the similar complaints and no improvement is observed.
Then she went to a hospital at khammam took treatment only for 2 days as they could not afford treatment they went to home.
At home she didn't take any medication for 10 days.
Then she came to our hospital with the complaints of
Abdominal distension which is insidious in onset,gradually progressive since 10 days
Swelling of both legs below the knees since 10 days which is insidious in onset,gradually progressive. It started at ankles and extending up to the knees.
History of decrease urine output,constipation since 10 days.
No history of abdominal pain,shortness of breath.
PAST HISTORY:
no similar complaints in the past.
Not a known case of diabetes, hypertension, epilepsy, tuberculosis, asthma.
PERSONAL HISTORY
diet - mixed
Appetite - decreased
Sleep - adequate
Bowel and bladder- irregular
No addictions
TREATMENT HISTORY
High carbohydrate diet
IV ceftriaxone
IV pantoprazole 40mg OD
IV zofer 4mg TDS
T. SAM 400 mg BD
T.hepatogen 400mg TDS
T.UDCA 300mg BD
FAMILY HISTORY
Her husband also had similar complaint of yellowish discoloration of eyes 6 months ago for which he took herbal medicine and symptoms subsided
GENERAL EXAMINATION
Patient is conscious, coherent, cooperative and malnourished
Icterus present
Bilateral pedal edema present
No pallor,cynosis, clubbing, lymphadenopathy.
VITALS
PULSE:92bpm,regular,normal volume,no radio radial delay,mo radio femoral delay.
BLOOD PRESSURE:110/80mm Hg,in sitting position, in the right arm.
RESPIRATORY RATE:22
TEMPERATURE: afebrile
GRBS:117mg%
LOCAL EXAMINATION:
ON INSPECTION
Abdomen is distended, umbilicus is everted, skin over the abdomen is stretched and shiny,Pfannenstiel scar present on lower abdomen,no visible pulsations, no visible gastric peristalsis, no engorged sinuses
All inspectory findings are confirmed
No local rise of temperature,no tenderness
No guarding and rigidity
No hepatomegaly
No splenomegaly
PERCUSSION
Shifting dullness present
no fluid thrill
AUSCULTATION
normal bowel sounds are heard.
No bruit
CENTRAL NERVOUS SYSTEM EXAMINATION
Muscle wasting of both upper and lower limbs 
Tremors - present
Higher mental functions-normal
CRANIAL NERVES - intact
MOTOR SYSTEM
Right left
1. Bulk wasting wasting
2. tone normal normal
3.power
Upper limb 5/5 5/5
Lower limb 5/5 5/5
REFLEXES
Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Knee jerk ++ ++
Ankle jerk ++ ++
No involuntary movements
SENSORY SYSTEM normal
No cerebellar signs
No meningeal signs
CARDIOVASCULAR SYSTEM
JVP, Apex normally placed, no Palpable P2, Heart sounds – normal, No thrills/murmur
RESPIRATORY SYSTEM
Chest symmetrical, No paradoxical movements, Normal vesicular breath sounds heard,
No abnormal/added sound
INVESTIGATIONS (25-07-2022)
21-11-2022
22-11-2022
Chronic liver disease secondary to ?hepatitis B with gross ascites.
TREATMENT
1. INJ.VIT-K 1 ampule in 10ml NS/iv/OD for 3 days
2. Tab. Aldactone 50mg/PO/BD
3. TAB. LASIX 20mg/PO/OD
4. TAB. RIFAGUT 50 mg/PO/BD
5. TAB.UDP LPV 300mg/PO/BD
6. SYP. Lactulose 15ml /PO/TID
7. INJ. CEFTRIAXONE 1gm/IV/BD
8. ASIRTOZYME 15ml/PO/TID
9. IV Fluids 10DNS slow iv over 10 hrs
10. Protein power 1-2 spoons in glass of water/TID
11. 3-4 egg white/day
12. fluid restriction <1 litre/day
13. Salt restriction <2gm/day
14.GRBS Monitoring 4th hourly
15. Monitor vitals
16. Inj. Zofer 4mg/iv/SOS
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