58 yr old Female with Abdominal distension and Sob

July 06, 2023

58 yr old Female 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 58 y old female resident of narketpally housewife by occupation came to opd

Chief complaints:

Abdominal distension since 10 days

Shortness of breath since 7 days

Pedal edema since 7 days

HOPI:

Patient was apparently asymptomatic 10 days back

Then she developed pain in the thighs for which she visited our hospital and took medication for that.

And then she developed abdominal distension which was insidious in onset and gradually progressive.

Abdominal tightness is present which is aggrevating after taking food.

She also had shortness of breath which is insidious in onset and gradually progessed to grade 3.

Patient also complained that she is gasping for breath after having meals so she even stopped having food properly.

Pedal edema is present since a week

Which is continuous , bilateral,pitting type and upto the knee level.

Past history:

She is known case of hypertension since 15 years and is on Tab. Telma 40 mg

Known case of hypothyroidism since 15 years and is on tab Tab.thyronorm

Known case of diabetes since 4 yrs and is on Tab.metformin 500mg

11 months back she was admitted in our hospital with similar complaints of abdominal distension,pedal edema and shortness of breath and after examination and investigations was diagnosed as Non alcoholic fatty liver disease.

Had 2 therapeutic ascitic taps done for symptomatic relief and was on medication since then .

She was having her routine monthly checkups since then

Since this 11 months patient had episodes of on and off pedal edema

Also complained of itching of skin all over the body which aggrevated on the days when she was constipated and also unable to pass the urine.

Now (6/7/23) Ascitic tap for done for diagnostic and therapeutic purpose and 600 ml of ascitic fluid was taken

Personal history:

She was married 38 yrs back has 2 children . Elder one is 36 old male married and younger one is 34 yrs old male unmarried. She is housewife does regular household work but due to complaints of sob, abdominal distension and swelling in legs she is unable to do her regular household work since 11 months .

Mixed diet

Appetite normal

Bladder movements-regular

Bowel - constipation (using Syrup:Lactulose )

Sleep - inadequate due to itching she couldn’t sleep properly

Addictions

Intake of beetle nut (pan) since 30 years

Daily routine :

Before 11 months:

She used to wake up at 5:00 am in the morning and get freshenup and do her regular house hold work of washing utensils , cleaning house,washing clothes and cooking upto around 9 am and then had her breakfast and used to watch Tv and then at 1 pm used to have her lunch and again household work at evng for 2-3 hrs and then has her dinner at around 9 pm and then used to go to rest .

Since 11 months:

She is unable to do any household work and just stays idle at home and even her appetite got reduced because of her distended abdomen .

Family history: No significant family history

General examination:

Patient was consious, coherrent and co-operative. Well oriented to time place and person.moderately built and nourished

Icterus -present