54 Y/O MALE WITH CLD, Subacute Intestinal Obstruction, Alcohol Dependence

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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.

 

Chief Complaints:

Patient was brought to the casualty with c/o 2 episodes of vomitings since morning on 16/12/23

and c/o distension of the abdomen since 3 months.

c/o shortness of breath since 3 days

no h/o fever, decreased urine output, chest pain, palpitations

o/e:

Icterus +. Muscle wasting +

HOPI:

Patient was apparently asymptomatic about 3 months ago, then he developed pain abdomen, distended abdomen for which he was diagnosed and treated as with CLD, ascites and jaundice.

Now he c/o abdominal distension and protruded umbilicus associated with 2 episodes of non projectile, non bilious, liquid in content with no blood in in the vomitus. Patient has h/o usage of herbal medicine 2 months back. No h/o diarhoea or bleeding p/r, or burning micturition.

PAST HISTORY:

N/K/C/O DM, HTN, CAD, CVA, EPILEPSY

No history of previous surgeries, or blood transfusions.

Hospitalised 6 months ago i/v/o jaundice, ascites- referred to a higher centre

Swelling of the abdomen on and off since last 5 months, abstinent from alcohol since last 5 months.

Personal History:

Married

Occupation: Borewell digger/ tractor driver 

Normal Appetite

Bowels and bladder are regular

No known allergies

Tobacco- chronic user- 1 pack khan over 3 -4 days since 24 years

Chronic alcoholic since 15 years of age.( 39 years)

Increased consumption since 30 years

Initially consumed 1-2 x a week with his cousins, 1 bottle.

at age 20, occupation changed to farmer, started drinking toddy , then arrack 180 ml per day,

4 times a week, whenever he felt pain.

After 2 years of drinking arrack- abstinent for 2 years.

Last 30 years- drinking whiskey 180 ml- strong urge- 180-360 ml/day

3-4 x 180 ml nights, 90 ml in morning if hands shake

continued til 20 years ago

10 years ago - jaundice, yellowing of sclera. Hospitalised and abstinent for 1 year

then again alcohol 2-3 x 180 ml almost daily increased if fearful

6 mo ago- jaundice, hospitalized with ascites , disoriented , recovered, hospitalised for 6 days and referred to higher centre and got well.

Swelling of the abdomen on and off for the last 5 months, abstinent for the last 5 months, since the last 2 weeks- 180-360 ml evening, 90 ml in the morning if hands shake.

Smokes 1 pack of KHAINI over 3-4 days.

FAMILY HISTORY:

NO SIGNIFICANT FAMILY HISTORY

PHYSICAL EXAMINATION:

GENERAL EXAMINATION:

NO PALLOR, CYANOSIS OR LYMPHADENOPATHY

ICTERUS, EDEMA, CLUBBING PRESENT

TEMPERATURE: 98 F

PR: 121 / MIN

RR: 22/ MIN

BP: 90/60

SYSTEMIC EXAMINATION:

ABDOMEN:

P/A: Distended, shifting dullness +,fluid thrill +, umbilical herniation +

DISTENDED

NON TENDER

UMBILICAL HERNIATION PRESENT

ORGANOMEGALY NOT APPRECIABLE

CVS: S1, S2 HEARD , NO MURMURS

RS: BAE +, No added sounds, CVS: S1, S2 heard, No murmurs.

CNS:DROWSY , AROUSABLE, SLURRED SPEECH

GCS- E 4 V5 M6

REFLEXES:

B/L REFEXES INTACT

INVESTIGATIONS:

CBP

RFT

LFT

USG ABDOMEN

CHILD PUGH SCORE;

10

MELD:

17

6 % 90 DAY MORTALITY

TREATMENT: