1801006123 - Short 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.

 

 

CHIEF COMPLAINTS: 

      A 40 Yr old male resident of Krishnapuram, Nalgonda dist, field assistant by occupation presented with the chief complaints of:

-  pain abdomen since 6 days

-  nausea and vomiting since 6 days 

- abdominal distension since 5 days

HISTORY OF PRESENTING ILLNESS:

      Patient was apparently asymptomatic 6 days ago, then he developed abdominal pain in epigastric region which is squeezing type, constant, radiating to the back and aggravated on doing any activity and relieved on sitting and  bending forward  .

- He developed nausea and vomiting which was 8-10 episodes which was non bilious, non projectile and food as content.

- H/o abdominal distension which was sudden in onset and gradually progressive to current size .

-  No history of fever, shortness of breath, cough , hemoptysis .

- No h/o orthopnea , pnd , fatigue , palpitations.

 - No h/o decreased urine output , burning micturition .

PAST HISTORY :

    - Known case of diabetes  and hypertension since 5 years

  - No history of asthma ,  TB , epilepsy and thyroid disorders.

PERSONAL HISTORY:

   Appetite: decreased

   Diet: mixed

   Sleep: disturbed

   Bowel and Bladder: regular 

   Addictions: history of alcohol intake for 5 years

 FAMILY HISTORY: 

  History of diabetes to patients mother since 14 years

  History of diabetes to patients father since 15 years 

GENERAL EXAMINATION:

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

 

Adequately built and Adequately nourished

 

     Pallor - Absent

     Icterus - Absent 

     Clubbing - Absent

     Cyanosis - Absent

     Lymphadenopathy -Absent

    Pedal Edema - Absent 

Vitals : 

Temperature - 99 F

Pulse Rate - 80 bpm

Blood Pressure - 130/90 mmHg 

Respiratory Rate - 13 breaths per minute and regular

 

SYSTEMIC EXAMINATION:

Patient examined in a well lit room, after taking informed consent.

PER ABDOMEN : 

 

Inspection - 

Shape - Uniformly Distended 

Umbilicus - displaced downwards 

Skin - No scars, sinuses, scratch marks, striae, no dilated veins, hernial orifices free

External genitalia - normal

Palpation - 

 

No local rise in temperature.

And tenderness 

Liver not palpable

Spleen not palpable

Kidneys are not palpable

Abdominal Girth - 84 cm

Percussion - 

Shifting Dullness - Present

Liver span - Normal

Spleen Percussion - Normal

Auscultation -

Bowel Sounds - Absent

No Bruit 

CARDIOVASCULAR SYSTEM EXAMINATION

Inspection - 

Chest Wall is Symmetrical

Precordial Bulge is not seen

No dilated veins, scars, sinuses

Apical impulse - Not Seen

Jugular Venous Pulse - Not Raised

 

Palpation - 

Apical Impulse - Felt at 5th Intercostal space in the mid clavicular line

No thrills, no dilated veins

Auscultation -

First and second sound heard 

No added sounds and murmurs

RESPIRATORY SYSTEM EXAMINATION

Inspection - 

 

Chest is symmetrical

Trachea is midline

No Scars, sinuses, Dilated Veins

All areas move equally and symmetrically with respiration

 

Palpation - 

 

Trachea is Midline

No tenderness, local rise in temperature

Tactile Vocal Fremitus - Present in all 9 areas

 

 

Percussion - 

 

On Percussion - resonant on both sides on all 9 areas 

On Auscultation - 

Bilateral air entry present 

Normal vesicular breath sounds heard

No added sounds 

Vocal Resonance in all 9 areas

CENTRAL NERVOUS SYSTEM EXAMINATION

All Higher Mental Functions are intact 

Cranial nerves intact 

No Gait Abnormalities

No Bladder Abnormalities

Neck Rigidity Absent

PROVISIONAL DIAGNOSIS: 

 

Ascites  secondary to pancreatitis 

INVESTIGATIONS

 

Random blood sugar - 540mg/dl

 

Hba1c - 7.6%

 

Ascitic fluid analysis

Protein - 5.1 g/dl

SAAG - 0.8 g/dl 

Albumin - 3.3 gm /dl

Amylase - 1055 IU / l

ADA - 15 IU/l

Cell count - 50 cells ( 70% lymphocytes ) 

Ascitic fluid culture negative 

 USG ABDOMEN

Mild to moderate ascites 

FINAL DIAGNOSIS 

Ascites secondary to pancreatitis .

MANAGEMENT

 

NPO

IV Fluids - N/S, R/L 125 ml/hr

Inj. PANTOP 40 mg IV BD

Inj. ZOFER 4 mg IV SOS

Inj, PIPTAZ 2.25 mg IV TID

Tab. TELMEKIND 40 mg PO OD

GRBS every 4th hourly

Inj TRAMADOL 1 amp IV

Inj, HUMAN ACT RAPID according to sugars