38 yrs old male with pedal edema , yellowish discoloration of eyes and epigastric tenderness.
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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.
*CASE:
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PROVISIONAL DIAGNOSIS:
A 38 yrs old male presented with the chief complaints of pedal edema and yellowish discoloration of eyes since 1 week,and epigastric tenderness since 5 days .
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 1 months back then his appetite was decreased since 1 month where he wanted to eat food but after taking 1-2 bites he cannot eat it. After eating food he is having nausea.
He also complained of intense burning micturition and also decresed urine output 20 days back. Both these symptoms have relieved now .
He also has generalised weakness since 20 days.
He had fever (only in night time and subsided by taking paracetamol)and loose motions 10days back. so they went to local clinic There they gave him IV fluids and some medication.There they did some investigations and had confirmed that he has jaundice.For which they used ayurvedic medicines for 4 days but after using them they observed no change they came to our hospital.
He has bilateral pedal edema pitting type which is extending from toe to knee since 7 days ,he complaints of pain in epigastric region since 6 days,and distended abdomen for which ascites fluid tap is done.
He also complaints of pus in the urine and pain after urination since 4-5 days.
DAILY ROUTINE:
He used to be a auto driver in past but now he is a daily wage labourer since COVID pandemic (i.e.,2019).
He wakes up at 6am and does his morning routine and eats his breakfast at 8am and goes to the field and does his work comes home in afternoon for lunch and again goes to do his work.He comes home in night at 7pm does his supper and sleeps.
He is a chronic alcoholic where he drinks daily compulsory since 18yrs more than 300ml per day and drinks more during festivals.
PAST HISTORY:
He has polyuria for which he consulted doctor and was diagnosed as diabetic 1 yr back
Not a k/c/o HTN,Asthma,tuberculosis,Epilepsy.
PERSONAL HISTORY:
Diet-mixed
Appetite- decreased
Sleep - adequate
Bowel and bladder movements- regular
Habits- alcoholic since 18 yrs (180 ml per day),
Smoking since 18 yrs (1 pack of bedi)
*FAMILY HISTORY:
No similar complaints in the family members.
*GENERAL EXAMINATION:
Patient is conscious coherent and cooperative.
Well oriented to time place and person.
Poorly build and malnourished.
Pallor -present
Icterus: present
clubbing: absent
cyanosis: absent
Lymphadenopathy: absent
Edema : bilateral pedal edema pitting type from toe to knee.
VITALS:
Temp: afebrile
BP: 120/80 mmHg
PR- 90 bpm
RR- 16cpm
SYSTEM EXAMINATION:
Abdominal examination-
Inspection: mild distended abdomen ,umbilicus everted.
Palpation:soft and tenderness in epigastric regions.
Percussion:Shifting dullness is present.
fluid thrill present.
Respiratory system-inspection- trachea central,normal respiratory movements,normal vesicular breath sounds.
Cardio vascular system- S1 ,S2 heard ,no murmurs
CNS Examination- no focal neurological deficits.
INVESTIGATIONS:
Chronic liver disease with chronic pancreatitis,and prostatic abscess.
*FOLLOW UP:
30/6/2022 -
He ate breakfast (vada),lunch(some rice and dal),dinner(rice with dal).
* 6:00 pm onward he is having fever and from 8:00pm (after dinner) onwards loose stools which is watery ,8 times.
*Treatment: Dolo for fever,
For loose motions-sporolac and metrozyl.
Antibiotics for prostatic abscess.
*1/7/2022-
He ate breakfast (vada),lunch (some rice and dal),dinner(rice with dal).
After dinner onwards loose stools started which are watery ,and 8 times.
Treatment:sporlac for loose motion
Diuretics for pedal edema.
Antibiotics for prostatic abscess
2/7/2022:
He has loose stools (7-8times) at night which are watery.
*Treatment:sporlac for loose motion
Diuretics for pedal edema.
Antibiotics for prostatic abscess.
3/7/2022:
He complaines of watery loose stools 7times at night .
Treatment:sporlac and metrozyl for loose motion
Diuretics for pedal edema.
Antibiotics for prostatic abscess.
4/7/2022:
4-5 times loose stools which are watery at night.
He complaines of pus with blood in the urine.
Investigations:
CBP:
Hemoglobin - 6.4
TLC. - 8,700
Neutrophils - 67
Lymphocytes- 30
PCV. - 17.9
RBC. - 1.9 million cells /mcL
Platelets. - 2.9 lakhs
*Treatment:sporlac and metrozyl for loose motion
Antibiotics for prostatic abscess.
Diuretics for pedal edema.
Thiamine injection-200mg i.v
Hepamarz 10mg
Fluid restriction
5/7/2022:
Loose stools 4 times ,at night.
Epigastric pain is reduced when compared with the starting days.
Investigations:
CBP:
Hemoglobin -6.0
TLC. - 8,900
Neutrophils - 72
Lymphocytes- 22
PCV. - 2.8
RBC. - 1.9million cells /mcL
Platelets. - 2.8 lakhs.
Upper Gastrointestinal endoscopy:
*Treatment:sporlac and metrozyl for loose motion
Diuretics for pedal edema.
Antibiotics for prostatic abscess.
Thiamine injection-200mg i.v
Hepamarz 10mg
Fluid restriction.
6/7/2022:
Loose stools reduced.
Epigastric pain reduced.
*Treatment:
Diuretics for pedal edema.
Antibiotics for prostatic abscess.
Fluid restriction.
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