60 year old male carpenter

 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 patient problem through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evidence input.

This E blog also reflect 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 attempts to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including history , clinical finding , investigation and come up with diagnosis and treatment plan.


A 60 year old male carpenter from Pavampur came to the hospital with- 

Chief complaints of- 

1. Enlarged stomach since 1 month 
2. Fluid retention in legs since 1 month. 
(Both complaints started at the same time)

History of presenting illness- 

The patient was apparently alright 1 month back then noticed enlargement of his stomach which was- insidious in onset, gradually progressive, and relieved on abstaining from alcohol. There are no aggravating factors. It is associated with squeezing type of pain in the umbilical region which is aggravated on eating food and working and relived on taking medications. it is associated with flatulence, constipation, fever and weight loss. it is not associated with nausea, vomiting, hematemesis, melena. 
The patient developed fluid retention in his legs 1 month back which is relieved on taking medications and is associated with cough and shortness of breath on walking for about 100m (Grade III MMRC).

History of Past illness- 

Patient has history of jaundice 10 years back for which he sought treatment.
The patient has history of 1 seizure episode 10 years ago. 
The patient has history of hypertension and diabetes mellitus since 7-8 years and is on medications. 
The patient has no history of chronic obstructive pulmonary disease, tuberculosis. 

Personal history- 

Daily routine- wakes up at 6am, has tea at 8 om, has breakfast (rice) at 9 am, works from 9am to 1 pm, has lunch at 1pm, drinks alcohol at 5pm, dinner at 7pm, sleeps by 9pm. consumes 20 bidis (1pack) a day. 
Diet- initially mixed diet but switched to vegetarian diet after seizure episode. 
Appetite- decreased since 1 month 
bowel movements- constipation 
Bladder movements- burning micturition and decreased urine output. increased urination on medications. 
Addictions- smoker and alcohol consumption for at least 40 years. 

Family history- 

History of diabetes mellitus in patients mother. 

General examination- 

I have taken consent for examination and examined the patient in a well lit room- 
The patient is conscious, coherent, cooperative and oriented to time place and person. 
The patient is adequately built and nourished. 
Pallor- present



Icterus- present

 
Clubbing- absent 
lymphadenopathy- absent
Edema- Bilateral pitting edema extending above the ankle. 


Respiratory rate- 15 breaths/minute
Pulse rate- 104 beats/minute
Blood pressure- 
Temperature- 
There is a cystic swelling in the lower third of the right leg



Systemic examination- 

Per abdomen- 

Inspection- 





Shape- symmetrically distended
Flanks- Full
Umbilicus- normal and inverted
Normal movements with respiration present 
No visible pulsations 
No visible peristalsis
Skin over the abdomen- engorged veins and stretch marks
Abdominal girth- 

Palpation- 

There is no local rise of temperature or tenderness. 
Inspectory findings confirmed
Liver- non palpable 
Spleen- non palpable 

Percussion- 

Shifting dullness- present 
Fluid thrill- absent

Auscultation- 

Bowel sounds heard

Cardiovascular system-

Inspection- 

Chest wall shape- elliptical and symmetrical
No pulsations, scars or sinuses

Palpation- 

Apex beat- 5 ICS midclavicular line
Parasternal impulse- absent
Thrills- absent

Auscultation- 

Heart sounds- S1, S2 heard
No added sounds or murmurs. 

Respiratory system- 

Normal vesicular breath sounds heard

Central nervous system- 

Higher mental functions intact
No focal neurological deficits

Provisional diagnosis- Decompensated alcoholic liver disease.

Investigations- 

GRBS- 




























Treatment-

1.Inj- HAI 6units IV/STAT
2.Inj.HAI  SC/TID 
3.Tab.LASIX 40mg PO/BD
4.Tab.PCM 650mg PO/OD
5. GRBS monitoring .



 

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