A 41 year old male came with complaints of abdominal pain and swellings in legs
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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.
CASE PRESENTATION
A 41 year old male who is a govt.surveyor by occupation from nalgonda came to general medicine OPD with chief complaints of abdominal pain and swellings of legs since 1 week.
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 1 week ago. Then he noticed abdominal distension associated with squeezing type of pain .No history of vomitings, diarrhea. And then five days back he had bilateral pedal edema which is of pitting type gradually from ankle to knee. Decrease in urine output not associated with burning micturition and SOB since 5 days.No history of fever and trauma chestpain,excessive sweating came to hospital on 2/ 1/ 2023.
PAST HISTORY
•Patients is not a k/c/o diabetes mellitus, hypertension, asthma, T.B and epilepsy
•No past Surgical history.
•3yrs ago he had a history of dengue and 2 yrs ago he had history of jaundice.
•He had blood transfusions in the past(2 units).
PERSONAL HISTORY
Mixed diet
Normal appetite
Inadequate sleep
Bowel and movements are normal and micturition is decreased.
Regular alcoholic
FAMILY HISTORY
Not relevant
GENERAL EXAMINATION
patient is conscious coherent and cooperative.
No pallor cyanosis, clubbing of fingers, lymphadenopathy
Bilateral pedal edema is present.
Icterus present
VITAL SIGNS
temp - 97.6 F
Pulse Rate - 92 bpm
Blood pressure - 110/ 70 mm hg
Respiratory rate - 18
Spo2 - 98 percent
SYSTEMIC EXAMINATION
CVS
S1 and s2 heard
No murmurs
No thrills
RESPIRATORY SYSTEM
no dysnea
No wheeze
Position of trachea: central
Vesicular breathe sounds
ABDOMEN
Shape of the abdomen: distention
No tenderness
No palpable mass
No organomegaly
Shifting dullness present
CNS
No facial asymmetry
All reflexes are normal
PROVISIONAL DIAGNOSIS
Chronic liver disease
INVESTIGATIONS
Ultra sound
TREATMENT
1)Fluid and salt retention
2)INJ.MONOCEF IGM/IV/BD
3)INJ.Asix 40mg/IV/BD
4)Tab.aldactone 50mg
5)Tab. Gabapentin 100mg
6)Syp. Lactulose 30 ml .
