A 50 yr Old male with abdominal distension

A 50 year old male with abdominal distention 

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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

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

CONSENT WAS TAKEN FROM BOTH PATIENT AND ATTENDERS 

Chief complaints : 

A 50 year old male came with  complaints of

-Abdominal distention and pain abdomen since 8 days

-Shortness of breath since 8 days

-Bilateral lower limb swelling since 6 days 

-Decreased urine output and yellowish discoloration of urine since 6 days 

HISTORY OF PRESENTING ILLNESS:

-Patient was apparently asymptomatic 8 days back

 then he had abdominal distention which was diffuse associated with abdominal pain which is squeezing type ;  aggravated with food intake .

-Complaints of bilateral pedal edema which is pitting type  extending from ankle to knee joint since 6 days.

-He had  decreased urine output  and yellowish discolouration of urine since 6 days 

-Not associated with fever with chills and burning miturition . 

-Complaints of shortness of breath with grade II which is decreased in supine position 

-No H/o hematemisis , melena 

PAST HISTORY:

-No similar complaints in the past.

-3 years back he was admitted in hospital for 15 days and  was diagnosed with dengue .

-2 years back he had jaundice for which he had a 2 PRBC transfusions 

-Recently 20 days back  he is having decreased vision so he went to checkup and diagnoses with cataract , he was adviced to stop alcohol so he stopped alcohol 15 days back 

Not a known case of HTN , Diabetes , asthma , TB , epilepsy , CAD , thyroid diseases 

Personal history 

He is a government revenue employee who wakes up at 6 am ;do his daily routine and  goes to his work . Most of the time he skips his breakfast and has lunch at around 2 pm to 3 pm and comes to home at around

6 pm  then he goes to drink alcohol-whiskey 180 ml  this was his daily routine since 12 years .

He takes mixed diet 

-Appetite  : decreased since 6 days

-Sleep       : adequate 

-Bowel      : regular

-Bladder   :decreased urine output since 6 days

-Addictions :Alcoholic since 12 years,he used drink 180 ml of whiskey twice a week but from last 6 years he began drinking 180 ml of whiskey daily, but stopped drinking 15 days ago. 

- No h/o smoking 

Family history 

No history of similar complaints in any of his family members 

GENERAL EXAMINATION  

Patient was conscious,coherent and cooperative.  Moderately built and nourished

-Pallor :  present 

-Icterus: absent

-Clubbing: absent 

-Cyanosis: absent 

-Lymphadenopathy: absent 

-Edema : present 

                      

VITALS:  

On 2/1/23 

Temp :  afebrile 

BP :  110/90 mmHg 

Pulse :  90 bpm 

RR :  22cpm 

Spo2 : 98%

On 3/1/23 

Temp:  afebrile 

BP : 110/70 mmHg supine position 

Pulse : 92 bpm 

RR : 20cpm 

Grbs : 101 mg /dl 

On 4/1/23

Temp: afebrile

BP: 110/70 mm Hg

Pulse: 82bpm

RR:18cpm

SYSTEMIC EXAMINATION 

PER ABDOMEN

INSPECTION:

-Abdomen is distended 

-dilated veins are seen 

-Flanks are full

-Umbilicus : flat 

PALPATION:

-No local rise of temperature 

-Abdomen is tense

-Abdominal girth : 92 cms 

-Mild tenderness over right hypochondrium 

-Liver and spleen are not palpable.

- Shifting dullness present 

- Fluid thrill absent 

PERCUSSION:

-A dull note is heard 

ASCULTATION:

-bowel sounds not heard clearly

Right side of abdomen

Left side of abdomen

Abdominal girth -92cm

RESPIRATORY SYSTEM:

INSPECTION:

- Trachea Is central

-Shape of chest is normal 

-Expansion of chest is equal of both sides

-No scars and sinuses 

PALPATION:

-no local rise of temperature and tenderness 

-All inspectory findings are confirmed 

PERCUSSION:

- resonant note heard 

ASCULTATION:

-Normal vesicular breath sounds heard

CVS : 

-S1 S 2 heard apex beat felt at 5th inter coastal space lateral to mid clavicular line  

-No murmors 

CNS examination 

HIGHER MENTAL FUNCTIONS:

Conscious, coherent, cooperative

Appearence and behaviour:

Emotionally stable

Recent,immediate, remote memory intact

Speech: comprehension normal, fluency normal

CRANIAL NERVE:

All cranial nerves functions intact

SENSORY FUNCTIONS

SPINOTHALAMIC TRACT

Pain , temperature ,presure- intact in all limbs

Posterior column:

Fine touch, vibration and proprioception are intact

MOTOR SYSTEM :  

                      Right          Left 

Bulk:  

Inspection.      N.              N 

Palpation.        N.             N 

Tone:  

UL.                  N.               N 

LL.                    N.             N

REFLEXES :

         B      T      S      K        A         P 

R      +       +       +       +       +        Flexor 

L       +      +      +       +         +        Flexor

CEREBELLUM:

  

Finger nose Incoordination - No 

Knee heel incoordination  - No 

DIAGNOSIS  

Decompensated liver disease  and  pancreatitis secondary to alcohol intake.

INVESTIGATIONS 

TREATMENT  : 

Ascitic tap was done but no fluid was drained 

•  Fluid restriction  less than 1.5 L /day

• Salt restriction  less than 2g/day

• Inj Lasix 40mg IV BD 

• Syp lactulose 30ml PO 

• Inj Monocef 

• TAB Aldactone 50 mg PO OD