42 YR OLD MALE WITH ABDOMINAL DISTENSION

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.







This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.





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.



42 YR Old Male Came to OPD with 
Cheif Complaints: 
Abdominal Distension since 10 Days 
Swelling In Both the legs since 5 Days 
 


HOPI : 
Patient  was apparently asymptomatic
2years back and then he  got Dengue Hemorrhagic fever  for which he admitted in a Hospital and There he also diagnosed with Jaundice for which he got Treated .

Later  13 days back then he developed Burning type of sensation in the upper and lower limbs which Aggrevates during nights  for which he consulted neuro surgeon and took medication, Gabapentin 400MG 



After that  he developed abdominal Distension 10 days back he also developed Swelling in the lower limbs.
He also complains of Shortness of breath ( Grade 4) , Pain in the epigastric region which radiates to the back 
History of Weight loss is present 



Past History : 
Not a known case of DM, TB , EPILEPSY, THYROID ABNORMALITIES ,ASTHMA 
History of Appendicectomy 10 yrs back 


Personal History : 
DIET : MIXED 
Appetite : Decreased 
Sleep  : Inadequate 
Bowel  and Bladder movements : Irregular
ADDICTIONS: Alcohol consumption Daily  since 6yrs around 180Ml daily 

FAMILY HISTORY: 
No significant Family History 


General Examination: 

Pateint is conscious ,Coherent , co operative 


 Moderatly built , Under Nourished 


Well oriented with time and Place 



Pallor - Present 
Icterus- Absent 
Clubbing - Absent 
Cyanosis - Absent 
Lymphadenopathy - Absent 
Edema - B/L Pitting Type of Edema is seen 



VITALS : 
TEMP : AFEBRILE 
BP : 130/80 mm HG 
pulse : 83BPM 
RR :21 cpm 


SYSTEMIC EXAMINATION: 
ABDOMEN : 

INSPECTION : 
On inspection abdomen is distended 
Appendicectomy scar is seen 
Prominent Veins on both Sides of abdomen are seen 

PALPATION:
Soft 
Mild Tenderness over Right Hypochondrium 
Liver and spleen are non palpable 




PERCUSSION: 
SHIFTING DULLNESS PRESENT 



AUSCULTATION :  
Bowel Sounds Heard 

CVS : S1 S2 Heard No Murmurs 
RESPIRATORY: Bilateral Air Entry Present 
Normal vesicular breath sounds .

CNS : NO focal Neurological Deficits 



PROVISONAL DIAGNOSIS: 
Ascites Secondary to Chronic liver Disease




INVESTIGATIONS : 

COMPLETE BLOOD PICTURE
Hemogram 
LFT
APTT 
Serum Creatinine 
Ascitic Tap 
Serum Electrolytes 
USG Abdomen
2D ECHO
ECG 
ENDOSCOPY






RX : 
Fluid Restriction to  <1L / day 
Salt Restriction to <2gms /Day 
Inj Lasix 40 mg IV 
BP, Pulse , Temp , RR charting 4th hourly 


 






















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