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 

 

Comments

Post a Comment

Popular posts from this blog

Image
 A 58 year old male, labourer by occupation, came to the OPD with the chief complaints of Shortness of breath since 30 days,which was worsened 1 day back(19/02/22), chest pain since 30 days ,facial puffiness since 30 days History of Presenting illness -   Patient was apparently asymptomatic 3 years ago then developed giddiness,  for which he went to a local hospital and was diagnosed as Hypertensive, for which he is taking T. Nicardia 10mg, T. Arkamine 0.1mg sos. Then 2 years back he  developed B/L pedal edema,  which progressed gradually to knees and  diagnosed with renal failure, started dialysis weekly twice. Since 4 months he developed left upper limb swelling and swelling at chest region,both of  which got  progressed to current size.  Back pain since 2 months, which got subsided on medication (T. Ultracet).  30 days back - he developed shortness of breath ,Grade II-III  which progressed to Grade IV since 30 days associated with orthopnea . Whereas from 4 days he developed right u
Read more

A 65yr old M with Hypoglycemia,Hypotension

Image
 A 65 yr old male patient, resident of miryalguda came with chief complaints of  Hypoglycemia. Pt came with  Hypoglycemia with Grbs 30mg/dl. Pt came to the surgery department with c/o multiple ulcers over lt leg since 6 months. Pt was apparently asymptomatic 6 months back then he developed 4 small ulcers of size 1x 1 cm initially, which was gradually increasing to attain present size.H/o fever which was on and off. Then he suddenly developed Hypoglycemic symptoms and became unconscious  and transferred to medicine department.No H/o trauma  H/o Fracture at left elbow joint which was ill treated - Non union of Fracture 30 yrs back. Pt is a K/C/O of DM and is on regular medication - T. Glimestarmil PO/OD Had H/o pulmonary cox 2 yrs ago. N/K/C/O HTN,Asthma,Epilepsy.  Married He worked as a Sarpanch in his village. Have Normal appetite with mixed diet and regular bowel and bladder movements.  No significant family history  General examination  Pt is c/c/c .  No pallor,Icterus, Clubbing,Cyan
Read more

1801006077 SHORT CASE

Image
 A 40 year old female patient ,hotel owner, resident of Narketpally came with chief complaints of Increased heartbeat since 6 months Breathlessness since 6 months HISTORY OF PRESENT ILLNESS : Patient was apparently asymptomatic 6 months back then she developed palpitations which were sudden in  onset, gradually progressive and develops under stress, heavy work. It lasts for 2 to 3 min and relives on rest . Since the last 2 to 3 months she complains of increased frequency and intensity of palpitations. She also complains of breathlessness ( shortness of breath) since 6 months and it was gradually progressive from grade 1 (6 months back)to 3 (presently)and it relieves on rest. Patient also has fainting attacks , headache when there is delay in food intake or prolonged standing and it gets relieved on taking rest or food. PAST HISTORY Not a known case of Diabetes, Hypertension, Asthma, Tuberculosis,Epilepsy, Thyroid disorders. Has acidity from past 15 years. She develops burning sensation
Read more