1801006062- SHORT CASE



 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.

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




HISTORY OF PRESENT ILLNESS 

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 

Bowel and bladder movements-constipation since 1year,urine output is normal

Addictions-He had H/o alcohol intake since his childhood 200ml/day and abstinence of alcohol from 1year

H/o smoking since childhood  18 cigars per day

GENERAL EXAMINATION:

Patient is conscious,coherent,cooperative and well oriented to time and place.

Moderately built and nourished

Pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy:absent

Pedal edema: B/L pedal edema is present





VITALS : 

Bp:130/70 mm/hg

PR:88/min

RR: 17 cpm

Temperature: afebrile 

Spo2: 96%


Systemic examination:

CVS: S1,S2 heard ,no murmurs

RS:
 Grade 3 dyspnoea,expiratory wheeze is present
Patient examined in sitting position
Inspection:-
oral cavity- Normal ,nose- normal ,pharynx-normal 
Shape of chest - funnel chest(Pectus excavation)
Chest movements : bilaterally symmetrically reduced
Trachea is central in position.

Palpation:-
All inspiratory findings are confirmed
Trachea central in position
Apical impulse in left 5th ICS, 
Chest movements bilaterally symmetrical 

AUSCULTATION 
BAE+,  NVBS

Abdomen:

On inspection:

Abdominal distention present
Skin over the abdomen is shiny 
Dilated vessels over the abdomen were seen 
Umbilical hernia is present (everted umbilicus)

Palpation:

Fluid thrill is absent but there is shifting of dullness
No tenderness and no palpable mass

Bowel sounds are heard

Liver and spleen are not palpable

 CNS:
No focal neurological deficits

provisional diagnosis:
ASCITES 

INVESTIGATION :

SAAG: 

Serum albumin : 2.1 g/dl 

Ascitic albumin : 0.22 g/dl

SAAG: 1.79 g/dl

Ascitic fluid protein sugar : 
Sugar -166 
Protein -2.5 
Ascitic fluid amylase :20.3
Ascitic fluid for LDH : 150 

TREATMENT:

-Inj.lasix 40mg/kg/BD
-Nebduolin 8th hrly
   Budicon 12th hrly
-Monitor vitals
-Tab.Azithromycin 500mg po/OD *3days
-Tab.Montek - hc po/OD *3days






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