60 yr old male

This is 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 patient’s problems through series of inputs from available global online 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 on 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. 

PRASUNA REDDY 
ROLL NO 59

50/M, HOTEL SUPERVISER,
C/O ABDOMINAL DISTENTION SINCE 3 MONTHS
SOB AND COUGH WITH SPUTUM SINCE 2MONTHS

PT WAS APPARENTLY ASYMPTOMATIC TILL 2019 THEN HE DEVELOPED AN EPISODE OF HEMOPTYSIS FOR WHICH HE VISITED HOSPITAL
THERE HE WAS DIAGNOSED WITH LIVER DS WHICH RESOLVED WITH UNKNOWN MEDICATION.
1 YR AGO, HE HAD GENERALIZED WEAKNESS, SOB GRADE 4, BLURRING OF VISION FOR WHICH HE WENT TO A LOCAL HOSPITAL WHERE IN A HEMOGRAM ,HB WAS 3G% FOLLOWING WHICH TRANSFUSION OF 5 UNITS OF PRBC WAS DONE
ON ENDOSCOPY, ESOPHAGEAL VARICES WERE DIAGNOSED
H/O POLYURIA, POLYDYPSIA


GENERAL EXAMINATION:
PT IS CONSCIOUS, COHERENT AND COOPERATIVE
AFEBRILE TO TOUCH
PR 96BPM
BP 110/80MM HG
RR 18CPM
SPO2 98%
GRBS 92MG/DL
PALOR+
NO ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA 


SYSTEMIC EXAMINATION:
CVS : S1 S2 HEARD
RS : 
BAE +
RHONCHI PRESENT( RT ISA,IAA)

P/A - DISTENDED SOFT , FLUID THRILL PRESENT.
  BOWEL SOUNDS HEARD

CNS - HMF INTACT
REFLEXES: B. T. S. K. A. Plantar
RT. ++. ++. +. ++. + flexion 
LT. +.+. ++. + + + + flexion
POWER 
UL 5/5. 5/5
LL 5/5 5/5 
no cerebellar / meningeal signs 

INVESTIGATIONS:



PROVISIONAL DIAGNOSIS:
1)DECOMPENSATED LIVER DISEASE WITH EVL DONE 3 MONTHS BACK FOR GRADE 3 VARICES 
2)HIGH SAAG LOW PROTEIN ASCITES WITH ANEMIA UNDER EVALUATION 
3) WITH MILD HYPOKALEMIA SECONDARY TO ?CLD 

TREATMENT:
24/12/22
1) INJ THIAMINE 1AMP 1N 100ML NS/IV/OD
2) TAB HEPAMERZ 500MG/PO/OD @2PM
3) TAB LASIX 40MG/PO/BD 8AM-8PM
4) TAB ALDACTONE 50MG/OD @2PM
5) TAB UDILIV 300MG/PO/BD 8AM-8PM
6) TAB RIFAGUT 550MG/PO/BD 8AM-8PM
7) SYP LACTULOSE 15ML/PO/TID
8) SYP GRILLINCTUS 15ML/PO/TID
9) VITALS MONITORING 6HRLY.
10) FLUID RESTRICTION <1L PER DAY 
11) SALT RETENTION < 2g / day

25/12/22
1)(D2) INJ THIAMINE 1AMP 1N 100ML NS/IV/OD
2) TAB HEPAMERZ 500MG/PO/OD @2PM
3) TAB LASIX 40MG/PO/BD 8AM-8PM
4) TAB ALDACTONE 50MG/OD @2PM
5) TAB UDILIV 300MG/PO/BD 8AM-8PM
6) TAB RIFAGUT 550MG/PO/BD 8AM-8PM
7) SYP LACTULOSE 15ML/PO/TID
8) SYP GRILLINCTUS 15ML/PO/TID
9) VITALS MONITORING 6HRLY.
10) FLUID RESTRICTION <1L PER DAY 
11) SALT RETENTION < 2g / day


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