60 YEAR OLD MALE WITH COMPLAINTS OF ABDOMINAL DISTENSION, BILATERAL LOWER LIMB SWELLING AND DARK STOOLS

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 60 year old male patient came to the OPD with chief complaints of 

• Distension of abdomen since 3 months

• Bilateral pedal edema since 1 month

• Dark stools since 4 days 


HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 11 yrs back and then he developed sudden onset of chest pain.

It was also associated with sweating

He then was diagnosed with CAD 

After 4 months he developed headache and neck pain and then was diagnosed as hypertension and diabetes and is on treatment since then. 

3 months back he noticed distension of abdomen associated with shortness of breath grade 3. He then went to local RMP and got treated. After 1 week he had a bout of vomiting with fresh blood. 

He was diagnosed with oesophageal varices and got treated.

On 23/11/21, he came to KIMS 


PAST HISTORY

He is a known case of HTN, DM, CAD

Not a known case of Asthma, Epilepsy, TB 


PERSONAL HISTORY

Diet- Mixed

Appetite-lost

Bowel and bladder-regular

Sleep- disturbed

Addictions- smoking but stopped 6months back 


FAMILY HISTORY 

No significant family history 


GENERAL EXAMINATION

Patient is conscious ,coherent and cooperative

Moderatley built and moderately nourished

Well oriented to time and place

Pallor +

Icterus absent

Cyanosis absent

Clubbing absent

Lymphadenopathy absent

Edema + 


VITALS

BP- 110/90mmHg

PR- 80bpm

RR- 17cpm

TEMP- afebrile 


SYSTEMIC EXAMINATION

CVS  S1 S2 + no murmurs 

PA  soft non tender distended  

CNS  no focal neurological deficits 

RS bilateral air entry + NVBS 


INVESTIGATIONS












PROVISIONAL DIAGNOSIS

 Chronic liver disease with portal hypertension.

Massive pleural effusion.


TREATMENT

TAB. LASIX 40 mg BD 

TAB ALDACTONE 50 mg OD

TAB PAN 40 mg PO OD

 FLUID AND SALT RESTRICTION

SYP. POTKLOR 10ml PO BD 

INJ. HAI S/C acc to grbs charting

 BP/PR/ TEMP CHARTING 4th HOURLY

 DAILY BODY WEIGHT AND ABDOMINAL GIRTH MONITORING

 GRBS MONITORING TID 

ICD CARE 

PROTEIN X POWDER 2 SCOOPS IN 100 ML MILK BD 

 

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