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 treatment plan.
Name : Kattekola Sathwik
Roll no : 58
2017 batch
A 65yr old Post menopausal non tubectomised female hailing from Suryapet District has presented to the OPD with the following complaints
* Loss of Appetite since 2weeks
* Tightness and distention of Abdomen since 2 weeks
* An episode of Giddiness 1 week ago
History of Presenting illness
The patient was apparently asymptomatic 2 weeks ago following which she developed Loss of appetite whoch progressed to present state. Intially she used to feel full after just eating 2 idlis. Now she skips a meal as she doesnt feel hungry
She also had complaints of distention and tightness of abdomen which started around same time which progressed to present state. She says that even if she drinks a glass of water the abdomen distends. There was also history of constipation. Before the onset of symptoms she used to pass stools 1-2 times per day. Now she passes stools once in 3-4 days .
No history of fever, pain abdomen, vomitings , jaundice, hematemesis , blood in stools, shortness of breath, alcohol consumption and significant loss of weight
The family was alarmed for her distention of abdomen for which she was taken to local hospital where she had undergone some basic investigations where she had an episode of giddiness for which she received medical attention.
Past history (medical)
No similar complaints in past
Not a known case of hypertension , diabetes , CAD, Asthma , Epilepsy, TB
No History of any blood transfusions.
Past surgical history:
She underwent cataract surgery for right eye 5 years back.
Personal history
* Loss of appetite -2 weeks
* Diet :- mixed
* Constipation :- present
* sleep :- Adequate
* No addictions
* No history of drug or food allergies
Family History
No history of Hypertension, Diabetes Mellitus, epilepsy, CAD, malignancies
General examination:
The patient is conscious, coherent and cooperative.
Moderately built and nourished
There is no pallor, icterus, cyanosis, clubbing, koilonychia, edema or lymphadenopathy.
Temp: afebrile
PR: 76 bpm
BP: 110/80 mmhg
RR: 16 cpm
SpO2: 98% on RA
GRBS: 110 mg/dl
Abdominal examination
Inspection
* The abdomen was grossly distended
* Stretch marks were present
* Umbilicus :- Flat
* No scars sinuses fistulae
* No engorged veins and visible pulsations
Palpation
* No local rise of temperature
*No tenderness
* Inspectory findings are confirmed
* Per abdomen is soft except in right hypochondrium where abdomen was soft to firm in consistency
* Fluid thrill :- present
Percussion :-Dull note was appreciated
Other systems examinations
Cardiovascular system :-Apical impulse was felt at 5th intercoastal space 1 cm medial to mid clavicular line
On auscultation, S1 S2 heard No murmurs
Respiratory system
*Trachea was central in position
* vesicular breath sounds were heard
Central nervous system
* Higher mental functions intact
* Cranial nerves, sensory and motor system - No abnormality detected
Provisional diagnosis
A case of Ascites for further evaluation
Course in hospital
The patient was admitted on 25.02.2022 with the co.mplaints an following investigations were done
BGT: A positive
Hemogram:
Hb: 12.2
TLC: 10,400
N: 83
Plt: 6.38 lakh
Impression: Normocytic Normochromic with neutrophilia and thrombocytosisq.
PT: 16
INR: 1.11
APTT: 31
BT: 2 min
CT: 4 min 30s
ESR: 25 m
Blood urea: 44
Serum creatinine: 1.1
Na: 137
K: 4.7
Cl: 104
RBS: 110 mg/dl
CUE:
Albumin: +
Sugar: Nil
Pus cells: 3-6 cells
Epithelial cells: 2-4
Serum amylase: 23
24 hour urine protein :- 63.1
Analysis of Ascitic fluid
Ascitic tap was performed and ascitic fluid was sent for Analysis
Appearance: cloudy
colour: yellow
TLC: 2500 (high)
Mesothelioma cells seen
Sugar: 84
Protein: 4.3
Alb: 2.5
Amylase:23.8
LDH: 751
SAAG: 0.2
Impression: Exudative Ascitic fluid
Based on SAAG value, there was suspicion of underlying malignancy or Tuberculosis
Microbiological analysis of Ascitic fluid :-(01/03/2022)
* Microscopy :- On ZN staining no acid fast bacilli were seen. On gram stain few pus cells were seen. No organisms were visualised
*Culture :- No growth after 72 hours of aerobic incubation
Chest X ray
USG Abdomen has shown Endometrial thickness of 11mm for which cross consultation with OBG was done. Upon cross consultation , Ovarian and Endometrial Malignancy was ruled out and for double confirmation
Treatment :-
1. Tab. PAN 40mg/OD
2. Tab. LASIX 20mg PO/BD
3. Tab. ALDACTONE 50mg PO/OD
4. Salt and fluid restriction.
5. Regular monitoring of vitals
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