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


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