LONG CASE

EVALOATION

Aseel Abdulkreem Alenzi

439017736
4th Year Medical Student
Medicine 2nd Rotation 12\2\2023
Group 7
CASE DISCUSSION EVALUATION

Case number: 1

4= Excellent
3= Very good
2 = Satisfactory
1 = Unsatisfactory

Skills 1 2 3 4
1- History: accurately states patient’s problem list
2- Demonstrate important physical examination
3- Analyse important investigation
4- Treatment and clinical judgment
5- Respond to Questions correctly
Overall score / 20

Evaluator’s name: …………………………………… Signature: ………………

Personal data
- Name: A.M
- Age: 66 years old .
- Sex: Male .
- Nationality: Egyptian.
- Residency: Riyadh city
- Address : Internal medicine department , king Salman hospital
- Date of admission : 16/1/2023

Chief complaint
Patient A.M 66 year old Egyptian male presented to the ER with complaining SOB for the last 7
days .

History of presenting illness

Patient A.M known case of diabetes presented to the ER complaining of shortness of breath
started gradually 7 days ago progressive in nature , aggravated with mild to moderate exertion
relieved by rest ‘in sitting position’ ,associated with non painful abdominal destination started 2
weeks ago gradually , he also notated yellowish discoloration in his eyes and lower limb edema
that started 9 days ago . the symptoms was interfere with his daily life and affecting his sleep .
there is history of night sweats , fatigue and fever with no history of decrease in appetite or
weight loss . the patient denies any history of cough , chest pain, hemoptysis , wheeze ,vomiting ,
hematemesis ,abdominal pain , dysphagia or odynophagia, heartburn diarrhoea or constipation,
hematochezia or melena, pruritus , change in urine colour .

Past medical history

- Patient is known case of T2DM for more than 20 years
- On Metformin 500 mg 3 times /day
- No history of any surgical procedure
- No history of previous hospital admissions
- No history of blood transfusion

- No known history of any allergy, to food or medications

- No history of herbal use or dietary supplementation ,

Family history
- No chronic illness or similar condition in his family
- Patient have 5 brothers all alive and healthy
Social history :

- Patient is engineer working in company

- Has good socioeconomic status
- He has been married for 45 years and have 2 daughters .
- his family living in Egypt
- he is currently Living in apartment with his brother
- Went to Egypt 2 months ago
- Patient denies any history of alcohol consumption
- Not smoker
- No history of any intravenous drugs injections , plasma transfusions, dental treatment
or tattooing

- Patient doesn’t have animals

Systemic review:

- CNS: there is no headache, No dizziness, no visual or speech disturbances, no loss of

consciousness, no convulsions no Motor or Sensory Disturbance.
- Cardiovascular: no tachypnoea ,no chest pain, no. palpitation, syncope
- Haematology : No history of easy bruising, prolonged bleeding, Petechiae, or Gum
bleeding
- Dermatology :no rash no pigmentation
- Genitourinary :Unremarkable as he has no change in ruination frequency or amount, no
change in urine colour no dysuria
- Rheumatology : Unremarkable as he has no joint pain or swelling no redness.

Physical Exam:
- Vital signs: HR: 71, BP: 120/66, Temp: 36.4 C, O2 sat: 98%, RR: 20,
hight:157 weight: 75 BMI: 35.8

- General inspection
- patient lies flat with the head resting on a 2 pillows
- looks ill and in respiratory distress, with significant abdominal desteonton , conscious
and oriented by time , place and person, not connected to anything
- While inspecting the face there was jaundice in sclera with conjunctival pallor and no
xanthelasma .
- In mouth poor dental hygiene was seen but no angular stomatitis , apthous ulcers or
central cyanosis.
- In neck no lymph nodes enlargement. no pigmentations. no raised JVP.
- While inspecting the hands no koilonychia no leukonychia but there was clubbing and
prolonged capillary filling time (more than 3 seconds) no palmar erythema no muscle
atrophy in the palms no tobacco staining . No flapping tremor.
 - Normal symmetrical pulse with regular rhythm and no radio-radial or radio-femoral
delay.

Focused GIT examination

Inspection:
- There was a visible abdominal distention flanks were full umbilicus is everted no visible
peristalsis, no surgical scars no abnormal stria no grey turner’s sign caput Medusae or
Cullen sign .
Palpitation
- On superficial palpation there was no pain or tenderness was seen
- On deep palpation no deep masses were detected, and no rebound tenderness
- Liver was not palpable nether spleen or kidney due to ascites
- There was bilateral pitting lower limb edema
Percussion
- shifting dullness and fluid thrill were present
Auscultation
- On auscultation normal bowel sounds no renal bruit ,no aortic bruit

Focused Respiratory examination:

Inspection :
- patient was in respiratory distress otherwise , No scars or any with normal bilateral
symmetrical chest movement during breathing.
Palpation :
- Normal chest expansion during breathing with no pain or tenderness seen.. No tracheal
deviation, normal tactile fremitus, in both lungs
percussion:
- Resonant in all regions
Auscultation:
- Normal bilateral vascular breathing and no added sound was heard.

Cardiovascular examination
Inspection:
- chest is bilateral symmetry , no scars or visible pulsation.
Palpation:
- Apex beat felt under the left nipple at the level of 5th intercostal space just lateral to
the midclavicular line, no thrill or heaves.
Auscultation:
 - Normal 1st and 2nd heart sound, with no added sound or murmurs.

Neurology examination: Cranial nerves examination Intact, Motor Examination:

normal position with no muscle wasting, abnormal movement or fasciculations

Summary
Patient A.M 69 years old male known case of T2DM for more than 20 years, was in his usual
state of health until 20 day ago when he developed abdominal detention and sob started 7 ago

On physical examination There was jaundice , significant ascites , lower limb edema and
clubbing

Management Plan :

- CBC
- Ascitic fluid analysis

- Liver function test

- Coagulation profile

- Hepatitis profile

- AFP level

- Kidney function test

- Electrolytes profile

- Blood glucose

- ABG

- US

- CT scan

- MRI
 Compete blood count : Liver function test :

AST 62U/L 5-40

MCV 93.8 FI 81-101
Alt 70U/L 5-40
MCHC 35.4G/DL 32-36
Albumin 17.1 G/L 32-46

MCHC 33.3 Pg 27-32 Billrubin total 74 Umol/L 0-34

Billrubin direct 42.19 Umol/L 0-3.4

Neuts % 63.7% 40-80

Coagulation profile :
Neut # 4.49 10*3/ul 2.5 - 7.5
Aptt 41.4 25-40

Baso 0.05 10*3/ul 0.02 - 0.1 INR 1,58 0.8-1.3

Pt 19.5 10-15
ESO 0.12 10*3/ul 0.02 - 0.5

Kidney function test :

Rdw 16.5 % 11.6 - 15.6
Creatinine 104.1 71-115
Neuts % 63.7% 40-80

Blood Urea 12.6 2.9-8.2

Neut # 4.49 10*3/ul 2.5 - 7.5

Baso 0.05 10*3/ul 0.02 - 0.1

ESO 0.12 10*3/ul 0.02 - 0.5

Rdw 16.5 % 11.6 - 15.6

Electrolytes profile :

Potassium 3.5 3.2-5.5

Chloride 100 98-107

Sodium 134 136-145

Ultra sound :

Xray :
Ct scan :

MRI :
Differential diagnosis :

- Portal vein thrombosis

- Budd chiari

- HCC

- Liver cirrhosis

- CHF

- TB

Management :
- Paracentesis
- Supportive treatment