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






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









Comments

Post a Comment

Popular posts from this blog

5 A vignesh

  B I M O N T H L Y    B L E N D E D  A S S E S S M E N T  [JUNE 2021] Name: A vignesh, MBBS [3rd Semester] ROLL NO: 05 Question 1: Competency tested for peer to peer review and assessment: I have been given the following assignment in an attempt to read, comprehend, analyze,reflect, clinical data including history, clinical findings,investigations and diagnosis.  ANSWER 01 Case 1 Review 1  https://caseopinionsbyrollno05.blogspot.com/ PULMONOLOGY  https://caseopinionsbyrollno05.blogspot.com/2021/05/medicine-blended-assignment-may-2021.html   the given case shows chief complaints of shortness of breath, pedal edema and facial puffiness. The case is very well presented and easily understandable GASTROENTEROLOGY  Case 2 Review  https://caseopinionsbyrollno05.blogspot.com https://caseopinionsbyrollno05.blogspot.com/2021/05/medicine-blended-assignment-may-2021.html      A 29 year old patient presented to hospital with developing abdominal pain and also vomitings which was suddn in onset .He
Read more

vignesh

Image
  GENERAL MEDICINE CASE PRESENTATION Vignesh Roll no:- 05 3rd semester  This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.This e-log also reflects patients centered learning portfolio. ●Case scenario  A 49 yr old female patient came to opd with the chief complaints of Shortness of breath(SOB) -grade IV and worsening  History of present illness •SOB -5 to 6 months On exertion •Pedal edema and facial puffiness since 5 to 6 months •Red urine output •Fever -10 days -subside on medication-intermittent and low grade •cough with sputum since 10 days History of past illness •k/c/o Hypertension-1 yr Treatment History  Hypertension Treatment since 1 yr •Temla 40  mg tab Personal H
Read more

A 63 yr old female

Image
 A 63year old female with c/o neck pain and b/l knee pain since 1 year. C/O decreases urine output since 1 year History of presenting illness:  Patient was apparently asymptomatic 1year back then developed neckpain,insidious ,gradually progressive, aggravated on bending forward and relieved with medication. C/O b/l knee pain since 1 year insidious in onset and gradually progressive relieved with medication.  C/o decreased urine output since 1 year, no burning micturition , no frequency/urgency /hesitancy. No pedal edema, no SOB, no palpitations, orthopnea,PND  C/o belching,burning sensation in epigatrium . Past history: K/c/o hypothyroidism since 2years and is on medication.  Not known case of DM ,HTN ,epilepsy, asthma, TB  Personal history:  Diet: mixed Appetite: normal Sleep: adequate  Bowel and bladder : regular Addictions: none  Daily rotinue: she wakes up by 6am in the morning freshens up and goes for a walk.  She has breakfast by 8am and watches TV.  Talks to neighbour's and
Read more