39 yr old male with Abdominal distension and bilateral pedal edema since 2 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

39 yr old male cab driver by occupation resident of west bengal came to opd with chief complaint of 

1.Abdominal distension since 2 months

2.Bilateral pedal edema since 2 months

3.decreased appetite since 2 months

4.decreased urine output since 1 month

HOPI:

Patient was apparently asymptomatic 2 months back then he developed abdominal distension which is insidious in onset gradually progressive associated with decreased appetite since then.In the same month he observed bilateral pedal edema upto knees which is of pitting type which increased on walking relieved with rest.after 1 month he observed decrease in urine output which is insidious in onset and gradually progressive 

No h/o fever, cough, breathlessness

Past history:

Not a k/c/o DM,Asthma,TB, Epilepsy, Thyroid disorders ,HTN,CKD,CVA,CAD

Personal history:

Diet :Mixed

Appetite : normal

Sleep: adequate 

Bowel and bladder movements: regular

Occassional Alcoholic (180ml weekly once) - stopped 1 yr back

Smokes Beedi 1pack/day --stopped 3months back

General Examination:

Patient is conscious,coherent and cooperative

Moderately built and nourished

Pallor, icterus, cyanosis , clubbing, Lymphadenopathy -absent

Bilateral pedal edema subsided

Vitals : 

PR : 76 bpm

BP : 110/80 mmHg 

RR : 20 CPM

Temperature : 98.4f

Spo2 : 98 % on RA

Abdominal girth:86cms

Weight:46kg

SYSTEMIC EXAMINATION:

Per Abdomen:

Inspection:

Shape - distended 

Flanks-full

Umbilicus - inverted

All quadrants moves equally with respiration 

No engorged veins, visible pulsations,scars,sinuses

Palpation:

All inspectory findings are confirmed 

No local rise of temperature

Abdomen is soft and non tender 

spleen and liver -not palpable 

No other palpable masses

Hernial orifice are free

Percussion:

Shifting dullness present

Fluid thrill present 

Auscultation:

Bowel sounds heard

Ascitic tap:

CVS:

Jvp not raised 

Inspection:

Shape of chest - elliptical

No visible pulsations

No engorged veins and scars 

Apical impulse not visible

Palpation:

Apex beat present over the left 5th intercostal space 1cm medial to midclavicular line

No parasternal heave

No precordial thrill

No dilated veins

Auscultation:

S1 S2 heard ,No murmurs 

Respiratory system:

Upper respiratory tract - normal

Lower respiratory tract-

Inspection:

Chest bilaterally symmetrical,

Shape- elliptical

Trachea- Midline

Palpation:

Trachea is Midline

Normal chest movements

Vocal fremitus is normal in all areas 

Percussion: in sitting postion

                            Rt.               Lt

Supraclavicular. N(resonant). N

Infraclavicular. N N

Mammary region. N. N

Inframammary region. N. N

Axillary region. N. N

Infra axillary region. N. N

Supra scapular region. N. N

Interscapular region. N. N.  

Infrascapular region. N. N

Auscultation:

Normal vesicular breath sounds

No added sounds

Vocal resonance is normal in all areas

CNS :

Higher motor functions - intact

Cranial nerves - intact

Motor system:

            Rt- UL. LL.           Lt- UL. LL

Bulk - normal N.           N. N 

Tone - N. N.                 N. N

Power - 5/5. 5/5.         5/5. 5/5

Reflexes:         

                       UL            LL

Biceps. 2+.  2+

Triceps. 2+. 2+

Supinator. 2+. 2+

Knee 2+. 2+

Ankle. 2+. 2+

Sensory system: intact

Co ordination is present 

Gait is normal

No Cerebellar signs 

No signs of meningeal irritation 

                   

                    

Investigations:

On 16/11/23

                                   On 17/11/23

                                  On 18/11/23

On 20/11/23

On 23/11/23

Provisional diagnosis:

Chronic Liver Disease

Treatment given:

1.Syrup.LACTULOSE 15ML PO HS

2.ZECOF COUGH SYRUP (5ml---5ml---5ml)

3.STRICT ALCOHOL ABSTINENCE