A 50 year old male with abdominal distention and pain abdomen
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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
The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted.
CONSENT WAS GIVEN BY BOTH PATIENT AND ATTENDERS
Chief complaints :
A 50 year old male a government revenue employee by occupation came with a Che if complaints of
★ abdominal distention and pain abdomen since 1 week
★shortness of breath since 1 week
★ b/l lower limb sweeping since 5 days
★decreased urine output and yellowish discoloration of urine since 5 days
★ loss of appatite since 5 days
History of present illness :
Patient was apparently asymptomatic one week back then he noticed abdomeninal distention which was diffuse associated with abdominal pain( squeezing type ) not associated with vomotings , loose stools , fever . aggravated with food intake .
Complaints of bilateral pedal edema which is pitting type gradually progressive, extending from ankle to knee joint
C/o decreased urine output and yellowish discolouration of urine since 5 days not associated with fever with chills and burning miturition , frothing of urine
No h/o chest pain , palpitations , excessive sweating .
Complaints of shortness of breath with grade II which is decreased in supine position
No H/o hematemisis , melena
He is a government revenue employee who wakes up at 6 am do his daily routine and hurriedly goes to his work mostly he skips his breakfast . up to 2 pm he doesn't have time he is busy with his respective work at 2 pm he takes his lunch and comes to home by 6 to 6:30 pm the he goes to drink alcohol( whiskey 180 ml ) this was his daily routine since 12 years .
3 years back the patient was admitted in hospital for 15 days he was diagnosed with dengue ( ? Coma)
2 years back he had jaundice for which he had a 2 PRBC transfusions
Recently 20 days back he is having decreased vision so he went to checkup and diagnoses with cataract , he was adviced to stop alcohol so he stopped alcohol 15 days back
Past history
Not a known case of HTN , Diabetes , asthma , TB , epilepsy , CAD ,CVD , thyroid diseases
H/o appendicectomy 17 yes back
Personal history
He takes mixed diet
Appetite : decreased since 5 days
Sleep : adequate
Addictions :Alcoholic since 12 years,he used drink 180 ml of whiskey twice a week but from last 6 years he began drinking 180 ml of whiskey daily, but stopped drinking 15 days ago.
No h/o smoking
Family history
Not significant
GENERAL EXAMINATION
Patient was conscious,coherent cooperative poorly build and nourished
Pallor : present
Icterus: present
clubbing: absent
cyanosis: absent
Lymphadenopathy: absent
Edema : present
Cataract :
VITALS:
On 2/1/23
Temp : afebrile
BP : 110/90 mmHg
Pulse : 90 bpm
RR : 22cpm
Spo2 : 98%
On 3/1/23
Temp: afebrile
BP : 110/70 mmHg supine position
Pulse : 92 bpm
RR : 20cpm
Grbs : 101 mg /dl
Systemic examination
Per abdomen :
On Inspection :
Abdomen is distended
Visible veins are seen
Flanks are full
A rash is seen in the region xiphoid process to left
Umbilicus : flat
An appendecectomy scar is present in right iliac fossa
Palpation :
No local raise of temperature
Abdomen is tense
abdominal girth : 93 cms
Mild tenderness over right hypochondrium
Liver and spleen are not palpable
On percussion
A dull note is heard
On auscultation
Decreased bowel sounds are heard
Respiratory system
On inspection :
Shape of chest is normal
Looks like symmetrically expanding
No scars and sinuses
Trachea is central
On palpation :
no local raise of temperature or tenderness
All inspectory findings were confirmed
Chest is symmetrically expanding On both sides
On percussion
Purssion note is same on both sides
On auscultation :
Bilateral air entry was present
Crepitus was heard in the right and left inframammary, supra mammary , infra axillary areas
CVS :
S1 S 2 heard apex beat felt at 5th inter coastal space lateral to mid clavicular line no murmors
CNS examination
HIGHER MENTAL FUNCTIONS:
Conscious, coherent, cooperative
Appearence and behaviour:
Emotionally stable
Recent,immediate, remote memory intact
Speech: comprehension normal, fluency normal
CRANIAL NERVE:
All cranial nerves functions intact
SENSORY FUNCTIONS
SPINOTHALAMIC TRACT
Pain , temperature ,presure- intact in all limbs
Posterior column:
Fine touch, vibration and proprioception are intact
MOTOR SYSTEM :
Right Left
Bulk:
Inspection. N. N
Palpation. N. N
Tone:
UL. N. N
LL. N. N
REFLEXES :
B T S K A P
R + + + + + Flexor
L + + + + + Flexor
CEREBELLUM:
Finger nose Incoordination - No
Knee heel incoordination - No
DIAGNOSIS
Decomoensated liver disease 2° to pancreatitis 2° to alcohol abuse
INVESTIGATIONS
TREATMENT :
Ascitic tap was done but no fluid was drained
• Fluid restriction less than 1.5 L /day
• Salt restriction less than 2g/day
• Inj Lasix 40mg IV BD
• Syp lactulose 30ml PO
• Maintain 2-3 times passage of stools
• TAB Gabapentin 100mg PO BD
• Inj Monocef
• TAB Aldactone 50 mg PO OD
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