58 y old female with CLD?NAFLD?
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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.
Name: P.Nikitha
Roll no: 102
A 58 y old female resident of narketpally housewife by occupation came to opd
With chief complaints of
Abdominal distension since 15 days
Shortness of breath since 10 days
Pedal edema since 7 days
And nausea
History of presenting illness:
Patient was apparently asymptomatic 15 days back
Then she developed pain in the thighs for which she visited our hospital and took medication for that.
And then she developed abdominal distension which was insidious in onset and gradually progressive.
Abdominal tightness is present which is aggrevating after taking food.
shortness of breath is present which is insidious in onset and gradually progessed to grade 3.
Patient also complained that she is gasping for breath after having meals so she even stopped having food properly.
Pedal edema is present since a week
Which is continuous , bilateral,pitting type and upto the knee level.
Past history:-
She is known case of hypertension since 15 years and was on tab Telma 40 mg
Known case of hypothyroidism since 15 years and was on tab thyronorm
Known case of diabetes since 4 yrs and was on tab metformin 500mg
History of similar complaints are present in the past
One year back patient got admitted in our hospital with similar complaints of abdominal distension,pedal edema and shortness of breath and after investigations was daignosed as chronic liver disease
And therapeutic ascitic tap was done for symptomatic relief and was on medication since then .
She was having her routine monthly checkups since then
In this one year patient had episodes of on and off pedal edema
Also complained of itching of skin all over the body which aggrevated on the days when she was constipated and also unable to pass the urine.
Personal history:-
Mixed diet
Appetite normal
Bladder movements-regular
Bowel - constipation
Sleep - inadequate due to itching she couldn’t sleep properly
Addictions
Intake of beetle nut (pan) since 30 years
Daily routine :-
Before the onset of disease she used to do the house hold work very actively
After the disease she is unable to do the things that actively
And since last 15 days it was much more reduced because of SOB
Family history: not significant
Treatment history:-
General examination:-
Patient was consious, coherrent and co-operative. Well oriented to time place and person.moderately built and nourished
icterus -present
B/L pedal edema-present (upto knee level-pitting)
No pallor,cyanosis,clubbing,lymphadenopathy
Vitals:
Temp: afebrile
Bp: 100/70 mmHg
PR: 72bpm
RR: 20 cpm
SpO2: 98% on RA
Systemic examination
ABDOMEN :
Abdomen - distended
Normal hernial orifices
Fluid thrill +
Dilated veins absent
No tenderness
No palpable mass
No organomegaly
No bruit heard
CVS :
S1 S2 + ,No murmurs
RESPIRATORY SYSTEM;
B/l symmetrical chest
Trachea - Central
B/l air entry present
NVBS heard
Investigations:
Provisional diagnosis
Decompensated chronic liver disease ?NAFLD with k/c/o HTN and hypothyroidism since 15 yrs
K/c/o DM-II since 4 yrs
Treatment
1.Fluid restriction <1L per day
2.salt restriction <2g/day
3.tab.udiliv 300mg PO/BD
4.tab.rifagut 550mg PO/BD
5.tab.lasilactone 20/5mg PO/OD
6.Syp.lactulose 10ml PO/TID
7.syp.hepumerz 10ml/PO/BD
8.tab.telma 40mg PO/OD
9.tab.metformin 500mg PO/OD
10.tab.thyronorm 25mcg PO/OD
11.inj.vit K IV/OD for 3 days
12.high Protien diet -2 egg whites/day
13.strict I/O charting
14.weight and abdominal girth monitoring
15.monitor vitals and inform sos
Acidic tap was done and about 600ml of fluid was removed
Pre procedure vitals:BP-100/50mmhg PR:92bpm
Post procedure:BP-120/80mmhg PR:86bpm
Link to the video
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