chronic liver disease
43yr old male with cld
April 20, 2023
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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 prognosis
A 48yr old Male autodriver resident of came to causality with chief complaints of :
Abdominal distension since 20 days
Bilateral pedal edema since 15 days
Decreased urine output since 10 days
Blood in stools since 10 days
Shortness of breath since 10 days
Loose stools since 4 days
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Patient was apparently asymptomatic 20 days back then he developed abdominal distension which is insidious in onset, gradually progressive to present size.
Bilateral pedal edema since 15 days Extending upto knee joint grade 2 pitting type sudden in onset no aggregating and reliving factors.
Decrease in urine output since 10 days
- times per day
Blood in stools since 10 days red in colour usually after motion, 4-5 episodes daily.
Shortness of breath since 10 days insidious in onset gradually progressive from grade 1 to 3 is more on exertion
No H/O orthopnea
PND
Fever
Nausea
Vomiting
Pain abdomen
Chest pain
Giddiness
Excessive sweating
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History of jaundice 6 months back and 2 months back.
Known case of hypertension since 12 years.
Not k/c/oDM,TB, EPILEPSY,CVA,CAD.
Family history:- not significant
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Appetite:- normal
Diet:- mixed
Sleep :- adequate
Bowel and bladder movements:- irregular
No drug allergies present
Consumes 360 ml of Whisky every day since 30 years stopped consuming for past 20 days.
No tobacco smoking and chewing.
General examination:-
Patient is conscious, coherent, cooperative well oriented to time, place and person .
Moderately built, moderately nourished
Icterus present
Bilateral pedal edema present
No pallor
No Cyanosis
No Clubbing
No Generalized lymphadenopathy
O/E :
Temp:- 96.8 F
PR- 72 bpm
BP- 130/90 mm of Hg
Spo2-100% at room air
RR : 16 cpm
GRBS- 121 mg%
On abdominal examination:
Inspection:
abdomen distended
Flanks are full
Umblicus is in position, everted
Skin over abdomen normal shiny, no scars, no sinuses, no nodules, no puncture marks.
No visible veins.
engorged veins. Are seen
Movements of abdominal wall are normal, no visible gastric peristalsis
Palpation:
Liver examination:
On superficial palpation
no tenderness , no raised temperature
On deep palpation
Liver is palpableNo tenderness in liver
Non pulsatile
Spleen examination:
No tenderness and pain
Not palpable
Percussion :
Presence of Ascitic fluid in the peritoneal cavity
Liver Span :
Auscultation
Normal bowel sounds heard.
2. Bruit - no renal artery bruit heard.
no iliac artery bruit heard.
Respiratory system examination :
Inspection :
Position of trachea central
No dropping of shoulders
No intercostal indrawing
No supraclavicular hallowness
Shape and symmetry of the chest normal.
No dilated veins.
No visible scars.
accessory muscles of respiration not prominentPalpation :
On three finger test : position of the trachea central.
Respiratory movements are normal
Measurement of left and right hemithorax :
Antero posterior diameter :
Transverse diameter at the level of nipples :
AP/transverse diameter ratio =
Distance between vertebrae and infrascapular angle on right and left side is same =
Vocal framitus :. Right. left
Supraclavicular area. N. N
Infraclavicular area. N. N
Mammary area. N. N
Axillary area N. N
Infraxillary area N. N
Suprascapular area. N. N
Interscapular area. N. N
Infrascapular area. N. N
Percussion :
On direct percussion in clavicular area
On right side : resonant
On left side :resonant
Tidal percussion: dullness in the right 5 th intercostal space even after deep inspiration.
Traubes space percussion : dull note
Ascultation :
Vocal resonence :
Right left
Supraclavicular area. N. N
Infraclavicular area. N. N
Mammary area. N. N
Axillary area N. N
Infraxillary area N. N
Suprascapular area. N. N
Interscapular area. N. N
Infrascapular area. N. N
Bilateral decreased vesicular breath sounds heard
Bilateral air entry present
No crackles heard.
CVS Examination :
Inspection :
No abnormal palsations
No visible scars.
No chest deformities.
Mediastinum normal
Trachea central in position.
Palpation :
Mediastinal position : apex beat palpable
Position of trachea central.
Percussion :
On percussion No cardiomegaly.
Ascultation : on examination of mitral area, pulmonary area, tricuspid area and aortic area S1 and S2 heard. No murmurs heard.
CNS :
Patient is conscious
Normal speech
No neckstiffness
Cranial nerves are intact and normal
Motor system intact and normal
Sensory system intact and normal
INVESTIGATIONS
Complete blood picture
Liver function test
Renal function test
Blood grouping
ECG
Chest x ray
Random blood sugar
Complete urine examination
HIV
HBsAg
2D echo
Provisional diagnosis :
Decompensated liver disease.
Treatment :
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