40 year old patient with hepatic encephalopathy

This is a online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patients problems through series of inputs from available global community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs .This E log book also reflects my patient centered online learning portfolio and your valuable inputs in comment box is welcome.

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 diagnosis and treatment plan .

CHIEF COMPLAINTS: 

Fever since 13 days

Chest pain on left side since 10 days

Loss of appetite since 10 days

HOPI:

Patient was apparently asymptomatic 8 months back , then he developed fever which was high grade , intermittent, associated with chills and rigor ,no diurnal variation, relieved with medication. Cough which was initially dry and then progressed to productive cough with scanty sputum, which was white coloured, non foul smelling, non blood stained.

Bronchoscopy was done and diagnosed with right lower lobe aspergilloma and started on Itraconazole 200 mg BD for 6 months. Patient recovered symptomatically and was fine till 13 days back . 

13 days ago, patient developed fever , which is of low grade , intermittent, no diurnal variation, not associated with chills and rigor .Chest pain which was of sudden onset 10 days ago , which is increasing with respiration and chest movements associated with palpitations and excessive sweating. Patient also has SOB which was initially of grade 2 and later progressed to grade 3 . Orthopnea is present.Patient was evaluated and found to have LV Strain , tall T waves and was treated symptomatically.

Loss of appetite since 10 days and bilateral pedal edema , pitting type extending till knee.

PAST HISTORY:

Right lower lobe aspergilloma on Tab. Itraconazole 200mg PO/BD

Not a k/c/o DM , HTN , epilepsy, asthma , CAD , CVD,TB

PERSONAL HISTORY:

Appetite-Decreased 

Diet - Mixed

Bowel and bladder - regular 

Sleep - Decreased.

General examination:

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

Pallor - absent 

Icterus - absent 

Cyanosis - absent 

Clubbing - absent 

Lymphadenopathy- absent 

Pedal edema - pitting type extending till knee 

VITALS :  Temp - 98.6 F

                  PR - 62 bpm

                 BP - 120/80 mmhg

                RR - 25 cpm

                SPO2 - 98% onRA

                GRBS - 102 mg/dl

Systemic examination: 

PER ABDOMEN:

Inspection :

Umbilicus is central and inverted

          All quadrants are moving equally with respiration 

          No scars , sinuses , engorged veins, visible pulsations .

          Hernial orifices are free.

Palpitation :

          Abdomen is soft and non tender 

          No organomegaly.

Percussion :

         Tympanic note heard over the abdomen.

Auscultation:

          Bowel sounds are heard.

CARDIOVASCULAR SYSTEM:

Inspection:

        Shape of chest is elliptical.

        No raised JVP

        No visible pulsations, scars , sinuses , engorged veins.

Palpitation:

        Apex beat - felt at left 5th intercostal space

        No thrills and parasternal heaves

Auscultation :

        S1 and S2 heard. 

RESPIRATORY SYSTEM:

Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

No scars, sinuses, engorged veins, pulsations 

Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: resonant bilaterally 

Auscultation:

 bilateral air entry present. Normal vesicular breath sounds heard.

CENTRAL NERVOUS SYSTEM:

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes    Right    Left

Biceps         ++         ++

Triceps        ++         ++

Supinator    ++       ++

Knee            ++       ++

Ankle           ++        ++

Investigations :

CBP :

         Hb – 14.3 gm/dl

         TLC – 7300cells/cu mm

         Neutrophils : 56

         Lymohocytes : 29

         Eosinophils : 07

         Monocytes : 08

         Platelets – 2.40 lakh/cu mm

Serum albumin - 3.37 gm/dl 

                           

CUE :

         Albumin - 

         Pus cells - 2-3/HPF

         Epithelial cells - 2-3/HPF

RENAL FUNCTION TESTS :

          Urea : 26 mg/dl

         Creatinine : 0.6 mg/dl

         Sodium : 132 mEq/L

         Potassium : 4.4 mEq/L

         Chloride : 101 mEq/L

LIVER FUNCTION TESTS :

         Total bilirubin : 1 mg/dl.

           Direct bilirubin : 0.23 mg/dl

           AST : 33 IU/L

           ALT : 37 IU/L

           Alkaline phosphate :208 IU/L

           Total proteins : 5.3gm/dl

           Albumin : 3.67 gm/dl

           A/G ratio :  1.75.

CHEST X RAY:

ECG : 

2D ECHO :