Case of 48 yr 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 and comprehending clinical data including history,clinical finding investigations and come up with a diagnosis and treatment plan.
A 48 year old male patient came to OPD with the following
Chief complaints:
Patient was apparently asymptomatic 20 days back when he developed abdominal distension which was insidious in onset ,gradually progressed to present state,diffuse in type
Distention is associated with SOB since 10 days initially while squatting currently even at rest(MMRC-grade-1to grade-4) ,distension doesn’t change with position ,not associated with orthopnea ,PND,abdominal pain ,vomiting.
Swelling of lower limbs since 15 days,Insidious in onset .Pitting type ,Initially involving only the feet later progressed Upto knees, Present throughout the day ,reduced on walking, no change at rest and raising the legs ,No Association with scrotal swelling.
No history of chest pain ,palpitations,facial puffiness .
History of high coloured urine since 20 days associated with decreased urine output since 10 days
Not associated with burning micturation,pain ,increased frequency, urgency .
History of yellowish discolouration since 2 years ,Insidious in onset ,Gradually progressive ,associated with high coloured urine ,not associated with itching ,pale coloured stools .
No history of 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
History of two hospital visits in past two years
History of generalised weakness ,abdominal distension two years back ,diagnosed to have chronic liver failure
Received rehabilitation,Abstained from consuming alcohol for 1 year
Started consuming alcohol ,followed by an episode of jaundice 1 year back with similar complaints of Generalised weakness ,abdominal distention
Patient is a known case of HTN since 10 years ,DM,TB,seizures ,heart diseases,thyroid abnormalities,
No history of blood transfusions,tattooing ,or chronic drug intake ,no history of recent travel
FAMILY HISTORY
No similar complaints in the family
TREATMENT HISTORY
T.Telma 80mg initially
Later was put on T.telma 40mg
T.amlong 5 mg currently
Atenolol 50 mg currently
SURGICAL HISTORY
No history of recent surgeries
PERSONAL HISTORY
Diet -mixed
Appetite -decreased
Sleep -adequate
Bowel and bladder -regular ,reduced output
Addictions -alcoholic since 13 years
Consumes 250-350 ml of whiskey everyday
GENERAL EXAMINATION
Patient is conscious,coherent and co operative well oriented to time place and person
patient is moderately nourished and moderately built
Height -5’7
Weight -48kgs
Pallor -absent
Icterus -present involving the upper bulbar conjunctiva
Cyanosis - absent
Clubbing - absent
Koilonychia - absent
Pedal Edema - present
HEAD TO TOE EXAMINATION
hair is normal
No parotid swelling
Palmar erythema- present
Petechae,purpurae -absent
abdominal scar -no
Vitals
Temp - afebrile
Heart Rate -72bpm
Pulse Pressure -130/90mmhg
Respiratory Rate -16cpm
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
Hernial orifices Normal
PALPATION
Abdomen is non tender , with rise of temperature due to fever
No guarding no Rigidity
No organomegaly
PERCUSSION
Liver
Upper border of liver dullness is per used at the right 6th 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 -present
Shifting dullness -present
AUSCULATION
bowel sounds heard
CNS
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
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
AUSCULATION
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, pulsations
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
AUSCULATION
bilateral air entry present.
Normal vesicular breath sounds heard.
Vocal resonance - reduced on left side mammary ,axillary ,infraaxillary areas
PROVISIONAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
Toxin induced liver damage
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