48 yr male with abdominal distension and sob
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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.
A 48 year old male resident of Chityala,Auto Driver by occupation came to OPD with
Chief complaints:
Abdominal distension since 20 days
Breathlessness since 20 days
Swelling of bilateral lower limbs since 20 days
Decreased urine output since 3 days
HOPI:
Patient was apparently asymptomatic 20 days back then he developed abdominal distension which was insidious in onset ,gradually progressed to present size . It is of diffuse type.and distension doesn’t change with change in position.
He also has history of Shortness of breath since 10 days which is insidious in onset and gradually progressive where initially he used to walk to his home without any problem after parking his auto at a distance from home.Now he has to take rest after walking such distance (grade 2) According to Mmrc grading
No h/o orthopnea ,PND, palpitations,sweating,chest pain
No h/o abdominal pain ,vomitting ,obstipation
He has bilateral swelling of lower limbs since 15 days which is insidious in onset , gradually progressive upto knee level, pitting type (grade 2) reduced on walking ,no change at rest and raising the legs
No h/o facial puffiness
History of high coloured urine since 20 days associated with decreased urine output since 10 days.
No h/o burning micturation,pain ,increased frequency and urgency .
History of yellowish discolouration since 2 years.
No h/o itching ,pale coloured stools .
No H/o fever ,headache ,rash ,joint pains ,no history of change in sleep pattern ,confusion ,altered sensorium ,no history of blood in stools, melena ,constipation .
Past history:
K/C/O HTN since 10 years (using t.amlong5mg and atenolol 50 mg )
Not a K/C /O DM,TB,seizures ,heart diseases,thyroid abnormalities.
No h/o of blood transfusions,tattooing , chronic drug intake .
Family history:
No similar complaints in the family
Treatment history:
T.Telma 80mg initially
Later was put on T.telma 40mg
Now using
T.amlong 5 mg
Atenolol 50 mg
Personal history:
Diet -mixed
Appetite -decreased
Sleep -adequate
Bowel and bladder -regular ,reduced output
Addictions -alcoholic since 2007
Consumes 250-350 ml of whiskey everyday after work in the night.
General examination:
Patient is conscious,coherent and co operative,moderately nourished and moderately built.
Weight -48kgs
PALLOR -absent
ICTERUS -present involving the upper bulbar conjunctiva
CYANOSIS -absent
CLUBBING -absent
LYMPHADENOPATHY -absent
PEDAL EDEMA -present (Pitting Type)
Head to toe examination:
hair is normal
No parotid swelling
Palmar erythema- absent
Gynaecomastia -absent
Pale coloured nails -present
Tremors -absent
spider naevi -present
Petechiae,purpurae -absent
abdominal scars - present (ascitic tap )
Vitals :
TEMP - 99.7° F
HEART RATE - 76 bpm
BLOOD PRESSURE - 160/70 mm Hg
RESP RATE - 16 cpm
Systemic examination:
Per abdomen:
Inspection:
Abdomen is distended in shape , with flank fullness
Umbilicus is everted
skin is normal
Spider neavi are present in upper back area
no discolouration of skin ,engorged veins ,sinuses
No visible peristalsis or pulsations
Palpation:
No local rise of temperature
No tenderness
No guarding
No Rigidity
No organomegaly
Percussion :
Liver
upper border of liver dullness is per used at the right 6 th inter coastal space along the mid -clavicular line on full expiration and the lower border cannot be palpated
Spleen
Castell’s method - dullness is observed in 9 th ICS of any axillary line
fluid thrill +ve
shifting dullness +ve
Auscultation:
bowel sounds heard
Cns examination :
Conscious,coherent and cooperative
Speech- normal
No signs of meningeal irritation.
Cranial nerves- intact
Sensory system- normal
Motor system:
Tone- normal
Power- bilaterally 5/5
Reflexes: Right. Left.
Biceps. ++. ++
Triceps. ++. ++
Supinator ++. ++
Knee. ++. ++
Ankle ++. ++
CVS examination:
Inspection :
Shape of chest- elliptical
No engorged veins, scars, visible pulsations
JVP - raised
Palpation :
Apex beat can be palpable in 5th inter costal space
No thrills and parasternal heaves can be felt
Auscultation :
S1,S2 are heard
no murmurs
Respiratory system:
Inspection:
Shape- elliptical
B/L symmetrical ,
Both sides moving equally with respiration .
No scars, sinuses, engorged veins
No hallowing , no crowding of ribs
Palpation:
Trachea - central
Expansion of chest is symmetrical.
Vocal fremitus - reduced on left side in mammary ,axillary and infraxillary areas
Percussion: stony dullness in left in left mammary ,axillary ,infraxillary areas
Tidal percussion-resonant note
Auscultation:
bilateral air entry present. Normal vesicular breath sounds heard
INVESTIGATIONS
Chest x ray:
Ascitip tap analysis:
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