CBBLE UDHC Similar cases

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 diagnosis with a treatment plan.

This is an online E log book to discuss our patient’s de-identified health data shared after taking his guardian’s signed informed consent. 

A 65 year old female, Hospital helping staff by occupation, came with complaints of : 

• Loss of appetite since 1 week 
• Tightness of abdomen since 5 days 
• 2 episodes of giddiness (one episode 3 days back and another episode 1 day back for which she received medical attention in a local hospital)

History of presenting illness:

Patient was apparently asymptomatic 1 week and then developed loss of appetite. She reports feeling full after consuming little amount of food. She feels full after consuming 2 idlis. She complained of not passing stools for 2-3 days but passed stools yesterday (24/2/22). 

Patient complains of Tightness of abdomen since 5 days. Abdomen is distended, non tender. Abdomen distension increases on eating. Flatus passed, stools passed yesterday but not with ease and was constipated for a while. Concerned about the abdominal distension, the patient was taken to a local hospital and was advised USG abdomen. After getting the scan done, patient felt giddy and was given NS infusion for it. Her attenders say she had not eaten anything that day and attribute that to the giddiness. There was no loss of consciousness. 

She had another episode of giddiness 3 days back as well. 

No history of fever, jaundice, hematemesis or malaena, pain abdomen, significant weight loss, alcohol consumption.

No similar complaints in the past. 

 

Attenders say that the patient is very active, wakes up early in the morning and does all her chores by herself. But has some difficulty in climbing stairs and occasionally complaints of knee pains. 

Past history: 

There is no history of diagnosis of Hypertension, Diabetes mellitus, thyroid disorders, epilepsy, tuberculosis or CAD. 

Past surgical history: 

She underwent cataract surgery for right eye 5 years back. 

No history of blood transfusions. 

Family History: 

No history of Hypertension, Diabetes Mellitus, epilepsy, CAD, malignancies. 

General examination: 

The patient is conscious, coherent and cooperative. 

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

On examination: 

• Inspection: 

Abdomen is distended

Engorged veins seen. 

Umbilicus is everted.

No sinuses,scars seen. 

• Palpation: 

Non tender. 

Subcutaneous nodules felt in right hyponchondrium region. 

Fluid thrill absent. 

•  Percussion: 

Dull note elicited. 

Investigations: 

BGT: A positive

Hemogram: 

Hb: 12.2

TLC: 10,400

N: 83 

Plt: 6.38 lakh

Imp: Normocytic Normochromic with neutrophilia  and thrombocytosis. 

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 

 

Chest X ray: 

Ascitic Tap was done today and approximately 400ml of fluid was aspirated. 

Treatment: 

1. Tab. PAN 40mg/OD

2. Tab. LASIX 20mg PO/BD

3. Tab. ALDACTONE 50mg PO/OD

4. Salt and fluid restriction. 

26/2/22

Ascitic fluid 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 the SAAG, the cause was suspected to be either.malignant or tuberculosis 

USG ABDOMEN was done to look for any malignancy or metastatic deposits.

USG ABDOMEN showed endometrial thickness 11mm, for which OBG referral was done. 

Upon referral, ovarian and endometrial malignancy were ruled out and for further confirmation endometrial aspiration was advised.