A 43 year old male came with complaints of abdominal distension since 3 days complaints of bilateral pedal edemas in 3 days
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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
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CONSENT WAS GIVEN BY BOTH PATIENT AND ATTENDERS
A 43 year old male came with
complaints of abdominal distension since 3 days
complaints of bilateral pedal edemas in 3 days
complaint of fever since 7 days
HISTORY OF PRESENT ILLNESSS : -
Patient was apparently asymptomatic 7 days back then he developed fever which was sudden in onset gradually progressive , low grade not associated with cough and cold .
History of abdominal distension since 3 days which is insidious in onset gradually progressed to present size .
History of bilateral pedal edema since 3 days insidious in onset gradually progressive in nature , aggravated on standing or working relieved on rest
History of melena present , 1 month back for a week , resolved on its own
History of vomiting one episode which is non bilious, non blood stained, non projectile in nature one month back
History of loss of consciousness 2 days back not associated with seizures
No h/o paina broken , loose stools , constipation , shortness of breath , palpitations
Patient had a history of fall 10 days back
He didnt gain consciousness for 5 days
And for 3 days he remained in that area where he fell and no one noticed him his attenders didnt found him for 3 days and a shepard found him in woods and then the attenders took him to nearer hospital and found that he s having low sugars (ie due to 3 days of starvation ?)
After that he developed jaundice , abdominal distention and pedal edema
He is a chronic alcoholic since 20 years and daily he will take about 90- 180 ml of alcohol the last time he dank was 13 days back and when ever he stopped he will experience severe sweating , shiviring , and generalized weakness
Patient was conscious,coherent cooperative poorly build and nourished
Pallor : present
Icterus: present
clubbing: absent
cyanosis: absent
Lymphadenopathy: absent
Edema : present
SYSTEMIC EXAMINATION
Per abdomen :
On Inspection :
Abdomen is distended
Flanks are full
Umbilicus : inverted and smilely
Scars were present below umbilicus
Palpation :
No local raise of temperature
Abdomen is tense
abdominal girth : 93 cms
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
Normal vesicular breath sounds were heard
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
Ascitic tapping was done on 21/11/2023 night and drained about 1200 ml of ascitic fluid
Link for ascitic tapping
Investigations
Provisional diagnosis
Chronic liver disease with Diabetes Mellitus type II
Soap notes
S :
Rx
1) fluid restriction ‹1.5 lit/day
2) salt restriction ‹ 2 gm /day
3) INJ THIAMINE 200mg in 100 ml NS/BD
4) T. RIFAGUT 550 mg OD
5) T. UDILIV 300 mg BD
6) T. DAPAGLIFLOZIN 5 mg + T. TENLIGLIPTIN 20 MG PO BD
7) SYP LACTULOSE 15 ML TID
8) T . LASILACTONE 20/50 BD
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