60 year old male with abdominal pain and distention since 3 months

 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.

A 65-year-old male resident of Erraram farmer by occupation came to GM OPD with chief complaints of abdominal pain since 3 months and abdominal distention since 3 months

Patient was apparently asymptomatic 3 months back then he developed abdominal pain sudden in onset, gradually progressive, initially on the right hypochondrium and then spread diffusely, dragging type of pain was observed, non-radiating type. No known aggravating and relieving factors.
Distention of stomach since 3 months sudden in onset, gradually progressive associated with shortness of breath from grade 1 to grade 3 according to MMRC scale as swelling progressed. No known aggravating and relieving factors.
No history of vomiting, diarrhoea, hematemesis, weight loss, constipation, dysphagia, melena, heart burn.
No history of decreased and increased micturition urine output, burning micturition
No history of chest pain, cough, cold, orthopnoea, palpitations, sweating, peripheral nerve disease

PAST HISTORY

Similar complaints were observed 3 years back which was treated and reduced on medication
History of ascitic tap 2 times in the past 3 months
History of Jaundice 2 years back which was treated with herbal medication
No History diabetes, hypertension, epilepsy, tuberculosis

FAMILY HISTORY

No similar complaints in the family

PERSONAL HISTORY

Diet: Mixed
Sleep: Disturbed
Appetite: Decreased
Bowel movements: Increased 3 to 4 times a day, green coloured
Bladder movements: Normal
Alcohol: Alcoholic for 20 years and stopped 3 years back stopped during his previous complaints and again started consuming after 6 months and stopped 3 months back. Every time he  consumes 360 ml.
No smoking history

GENERAL EXAMINATION

Patient is conscious, coherent, and comfortable
No pallor, No icterus, No clubbing, No lymphadenopathy, No pedal edema, No cyanosis






VITALS

Temperature: 98.6F
Pulse rate: 90 bpm
Respiratory rate: 18 cpm
Blood pressure: 110/70 mmHg

ABDOMEN EXAMINATION

INSPECTION

Shape of the stomach is distended, flanks are full, umbilicus is central and on the level of the skin, No scars, sinuses, dilated veins
Movement of abdominal wall equal and symmetrical
No visible gastric peristalsis
Intact Hernial orifices

PALPATION

No tenderness, no local rise of temperature
LIVER: Non tender, lower border of the liver could be palpated upon inspiration in the right hypochondrium, I could not palpate the upper border on palpation
SPLEEN: Not palpable
KIDNEY: Non tender, bimanually palpable in the right and left lumbar regions.
ABDOMINAL GIRTH: On inspiration 87cms and on expiration 82cms

PERCUSSION

Shifting dullness is present
Fluid thrill not present
Liver span checked and seen 12cms
No hepatomegaly, No splenomegaly

AUSCULATATION

Bowel sounds heard 9 times in a minute
No bruits heard

CARDIOVASCULAR EXAMINATION

S1, S2 heard, No murmurs

RESPIRATORY SYSTEM

Non vesicular breath sounds heard on bot the sides no added sounds

CENTRAL NERVOUS SYSTEM

Patient is conscious, coherent, and comfortable
Cranial nerves intact
Sensory system intact
Motor system tone, bulk, and power normal on all four limbs

DIAGNOSIS

Chronic decompensated liver disease with ascites and hepatitis B positive

INVESTIGATIONS

SERUM CREATININE



SERUM ELECTROLYTES



LIVER FUNCTION TESTS



HEMOGRAM



COMPLETE URINE EXAMINATION



2D ECHO



ULTRASOUND



TREATMENT

Fluid restriction
Protein powder
Tab. Lasix
Tab. Aldactone
Tab. Udiliv
Lactulose syrup
Tab. Benformet


Comments

Post a Comment

Popular posts from this blog

A 45 year old male with chest pain

Image
Patient came with chief complaints of chest pain 1 episode 6 days back Patient was apparently alright 10 to 12 years when he developed increased drowsiness for which he consulted a doctor and was diagnosed to have hypothyroidism for which he used medication for 2 to 3 years and stopped it.he developed generalised body pains more on the neck and back insidious in onset, intermittent aggravated on working and relevied on taking rest.  Then 1 week back after his dinner (non veg) he started feeling tightness in his chest(like acidity in patients words) and started feeling hot and his breath became heavy for which he tried to on the fan and became unconscious as he got up. The pain was localised non radiating. When he got unconscious his family members observed that he was profusely sweating and pass urine involuntarily following which his family members took him to the hospital for which treatment was done for coronary artery disease, acute inferior wall mi with EF 45% He later got con...
Read more

MY EXPERIENCES WITH GENERAL CELLULAR AND NEURAL CELLULAR PATHOLOGY IN A CASE BASED BLENDED LEARNING ECOSYSTEM'S CBBLE

 MAY 30TH 2023 This in Harthik choppa a medical student from India. Welcome to my blog where you can see how my general medicine changed my view of seeing general medicine as a mere subject which has to be studied for the sake of exams to general medicine being an interesting, immersive journey which covers each and every aspect of our amazing human body. We had an open platform where we could discuss things and we approached our HOD sir and seniors directly many times where our doubts were cleared with an open mind without any judgement. As medical students we learned a lot of different ways to diagnose and treat a patient in different scenarios practically bedside rather than studying books for hours and hours. I am very much excited to share this journey over the past 3 years Coming to my first case,  It was a 65 old female who was quite alright when I saw her my first impression on the lady was she is perfectly alright so I was intrigued on why she came to the hospital as ...
Read more

60Y old male with sob, abdominal distention and bilateral pedal edema since 4 days

Image
  Patient came with chief complaints of shortness of breath since 4 days, pedal edema since 4 days and abdominal distention since 4 days Patient was apparently asymptomatic 5 years back when he had an injury to the left leg by a thorn prick for which doctor advised him to keep ice over it. He did this for 5 days when he noticed swelling accompanied by blebs. Swelling was localised and associated with pain which was non radiating, no know aggravating or releiving factors for which he was admitted and dressing was done for 1 week and later ok discharged after the swelling had reduced. During this visit to the hospital he was given a pint of blood transfusion due to decreased heamoglobin count. The patient complains of neck pain from 10 years has history of lifting heavy weights on shoulders, non radating, no known aggravated and releving factors. Some releif on using collar. Use it when he is unable to bear it. H/o knee pain since 10 years bilateral non radiating aggravates on walkin...
Read more