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Name: ...

Age : 87 years old

Occupation : Retired policeman

Add: .Cakang,Muar

Admitted 1 month ago(Not sure about the date)

Date of examining: 


Chief complaints: Patient came with the chief complaints of distended abdomen,                                                                                                                     genitalia, and limbs. And itchiness all over his body for 10 days prior to admission.


Past history: Not significant 


Family history: Not sure


Personal history: patient is on balanced diet, Smoker for 2 years 32 years ago, Bladder habits are normal, patient used to pass stools 2 times a day but after admission has not pass stool yet, there is history of loss of appetite and sleep disturbed.
 


General physical examination

Patient is conscious, unable to communicate, lying on supine position with head end elevated.Patient is on nasal oxygen prong and nasogastric tube. There is an IV cannula attach to dorsum of left hand with was infused with dextrose 5%.folles catheter  attached to urinary beg. there is alopecia icterus, arcus senalis,poor oral hygine, generalized edema , no pallor cyanosis and lymphadenopathy


Vital signs

Pulse :rate was 72

           regular rhythm,

           normal volume ,

           normal character

          there is no blood vessel thickening

Blood pressure: 110/70mmhg

Respiratory rate: 20 breaths per minute

Temperature: A febrile
 
 


Systemic examination (positive finding)


Respiratory system: On inspection chest movements are diminished on right site

                                 Skin appear shiny and stretched

                                 On auscultation croup crepitations heard on both sites
 
 
 
 


Abdomen:

          on inspection: Distended

                  Flanks are full

   Umbilicus everted

No blood vessel thickening

No abnormal pulsation

No dilated veins

No scar

Peristalsis movements not seen

   


  On palpation : There is local rise of temperature

                            Abdomen is firm

                            No tenderness   

                                     No palpable mass

                                     Hepatomegaly and splenomegaly is cannot be elicited


           On percussion: Dullness present over all the areas except epigastric region and

                                      umbilical area

fluid thrill Positive


Provisional diagnosis: Acute liver failure


Differential diagnosis: Renal failure 
 


Investigations done on this day (12th June 2006)


Liver function test Result  Normal value
Total protein 63 g/l  65-85 g/l
Albumin 25 g/l 35-50 g/l
Globulin 38 g/l 20-35 g/l
Bilirubin  30 mmol/l < 22.2 mmol/l
Alkaline phosphate 139u/l 53-128 u/l
Serum creatinine 147 mmol/l 40-115 mmol/l
chloride 112 mmol/l 98- 108 mmol/l
Clothing factor  Result  Normal value
Prothrombin  13.5 sec 9.0- 12.4 sec
APTT 30.9 sec 20.8-3o.8 sec

 
 
 
 
 

  ON follow up 14th june 2006 


Patient was put on cvp line which has been stopped, according to the doctor central venous pressure was slightly raised. 


Investigations   


Renal function test Result  Normal value
Serum creatinine 171 mmol/l 40-115 mmol/l
Urea & electrolytes  10.8 mmol/l 2.5- 8.3 mmol/l
Sodium  141 mmol/l 135-145 mmol/l
Potassium  50 mmol/l 3.5-5.0 mmol/l   
chloride 116 mmol/l 98- 108 mmol/l
     
Full blood count  Result  Normal value
Hb  10.3 g / dl 13.0- 18.0 g /dl
hematocrit 33.9% 40-52 %
Mean cell volume  111.1 80-95

 
 
 
 

ON EARLY MORNING 15th June 2006 MY PATIENT PASSED AWAY.ACCORDING TO THE NURSE THE PATIENT’S BLOOD RESSURE WENT DOWN TO  100/40MMHG AND HIS  PaCO2 WENT UP TO 88MMHG (HYPERCAPNIA).