60 yrs old male carpenter

 60 year old male carpenter


July 10, 2023


 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 patient problem through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evidence input.

This E blog also reflect 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 attempts to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including history , clinical finding , investigation and come up with diagnosis and treatment plan.



A 60 year old male carpenter from Pavampur came to the hospital with- 



Chief complaints of- 


1. Abdominal distension since 1 month 


2. Generalized swelling of lower limbs since 1 month. 





History of presenting illness- 


The patient was apparently asymptomatic  1 month ago,  then noticed distension of abdomen  which was- insidious in onset, gradually progressive, and relieved on abstaining from alcohol. 

There are no aggravating factors. 

It is associated with squeezing type of pain in the umbilical region which is aggravated on eating food and working and relived on taking medications. 

It is associated with constipation, fever and weight loss.

 It is not associated with nausea, vomiting, hematemesis, melena. 


The patient developed pedal edema  1 month ago  which is relieved on taking medications and is associated with cough and shortness of breath on walking for about 100m (Grade III MMRC).



History of Past illness- 


Patient has history of jaundice 10 years back for which he sought treatment.


The patient has history of 1 seizure episode 10 years ago. 


The patient has history of hypertension and diabetes mellitus since 7-8 years and is on medications. 


The patient has no history of chronic obstructive pulmonary disease, tuberculosis. 



Personal history- 



Diet- initially mixed diet but switched to vegetarian diet after seizure episode. 


Appetite- decreased since 1 month 


bowel movements- constipation 


Bladder movements- burning micturition and decreased urine output.  


Addictions- smoker and alcohol consumption since 40 years


Daily routine

Daily routine- wakes up at 6am, has tea at 8 om, has breakfast (rice) at 9 am, works from 9am to 1 pm, has lunch at 1pm, drinks alcohol at 5pm, dinner at 7pm, sleeps by 9pm. consumes 20 bidis (1pack) a day. 


Family history- 


Not significant 



General examination- 


I have taken consent for examination and examined the patient in a well lit room- 


The patient is conscious, coherent, cooperative and oriented to time place and person. 


The patient is adequately built and nourished. 


Pallor- present



 

Icterus -absent

Clubbing- absent 

Cyanosis absent

lymphadenopathy- absent

Edema- Bilateral pitting edema extending above the ankle. 



VITALS 

Respiratory rate- 15 breaths/minute

Pulse rate- 104 beats/minute

There is a cystic swelling in the lower third of the right leg.




Systemic examination- 

Per abdomen-

 Inspection- 





 


Shape- symmetrically distended

Flanks- Full

Umbilicus- central and  inverted

All quadrants are moving accordingly with respiration.

No visible pulsations 

No visible peristalsis

Skin over the abdomen- engorged veins and stretch marks


Palpation- 


There is no local rise of temperature or tenderness. 


Inspectory findings confirmed


Liver- non palpable 


Spleen- non palpable 


Percussion- 


Shifting dullness- present 


Fluid thrill- absent


Auscultation- 


Bowel sounds heard



Cardiovascular system

Heart sounds- S1, S2 heard


No added sounds or murmurs. 


Respiratory system- 


Normal vesicular breath sounds heard


Central nervous system- 


Higher mental functions intact


No focal neurological deficits


Provisional diagnosis-

 Decompensated alcoholic liver disease.


Investigations-





















Treatment-


1.Inj- HAI 6units IV/STAT

2.Inj.HAI  SC/TID 

3.Tab.LASIX 40mg PO/BD

4.Tab.PCM 650mg PO/OD

5. GRBS monitoring .




 

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