45 year old male with ascites

July 28, 2022

THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT

chief complaints :

45 year old male who is a resident of Nalgonda and Sheperd by occupation presented to the hospital with chief complaints of shortness of breath and cough since 6 years abdominal distention , facial puffiness , pedal edema since 3 years

HOPI

patient was apparently asymptomatic 6 year back and then he developed shortness of breath which is insidious in onset gradually progressive which is grade 2 (MMRC grading ) .

Then he developed cough which is productive with sputum which is yellow in colour and non blood stained

There is history of abdominal distention since 3 years which is insidious in onset and gradually progressive then he consulted a local doctor and used medications but then its not relieved and continued to progress for which he came here .

He also has history of facial puffiness and pedal edema for which he is on medications .

History of constipation since 1 year .

No history of vomiting , fever, jaundice , orthopnoea , PND, chest pain , palpitations , weight loss.

DAILY ROUTINE:

He wakes up in the morning by 6'o clock and goes to the work by 9'o clock after having breakfast and he will have his lunch by 1 in the afternoon and continues with the work then he goes back to home by 6 pm in the evening .

PAST HISTORY:

No similar complaints in the past

Not a known case diabetes , hypertension , asthma, TB, epilepsy

He has a H/o liver infection 1year ago which had got relieved with medication.

Treatment history:

Right IOL implantation in 2021

Family history:

Not relevant

Personal history:

Diet : mixed

Appetite-normal

Sleep-inadequate