Hi, I am Manasvi Peddineni, 5th sem medical student. This is an 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 book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.
I've 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 a diagnosis and treatment plan.
CONSENT AND DE-IDENTIFICATION :
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout this piece of work whatsoever.
Chief Complaint: A 44 year old male, resident of Miryalguda, came to OPD with chief complaint of bilateral pedal edema and swelling of abdomen since 1 week.
History of Presenting Illness: Patient was apparently asymptomatic 1 week ago when he developed bilateral pedal edema, pitting type, no aggravating and relieving factors.
He also had abdominal distension since 1 week, sudden in onset, gradually progressive, not painful, uniformly distended with flanks full, aggravates on exertion and relieves by medication.
He had abdominal discomfort and tightness, since 1 week which was gradually progressive and intermittent.
He had complaint of fever since 1 week, low grade, not associated with chills and rigors, aggravates at night.
He had constipation since 1 day.
He had h/o dry cough since 4 days.
No h/o loss of appetite, nausea and vomiting, loose stools.
No h/o burning micturition, decreased urine output.
No h/o SOB.
Past History:
He had similar complaints in the past 2 years ago which was treated by unspecified medication.
He has h/o B/L chest tenderness since 1 year, aching type, aggravates on touch and relieved on medications.
He had h/o B/L lower limb pruritis and numbness 2 years ago which was associated with pain.
Not a k/c/o DM, HTN, CAD, TB, asthma, epilepsy, thyroid disorders.
H/o 2 blood transfusions before getting admitted to our hospital and 4 blood transfusions under our supervision.
Surgical History: no previous surgical history
Family History: no significant family history
Drug History:
Personal History:
- married
- normal appetite
- mixed diet
- regular bowels
- normal micturition
- no known allergies
- chronic alcoholic, consumed around 60ml per day but stopped 2 years ago
General Examination:
I have examined the patient after taking prior consent and informing the patient in the presence of a female attendant. The examination was done in both supine and sitting position in a well lit room.
- patient was conscious, coherent and cooperative
- well oriented to time, place and person
- well built and adequately nourished
- no pallor
- icterus present
- no cyanosis
- no clubbing of fingers
- no lymphadenopathy
- B/L pedal edema, pitting type
- no malnutrition
- no dehydration
Vitals:
temperature: afebrile
PR: 83 bpm
RR: 20 cpm
BP: 110/70 mm of Hg
Fluid Intake and Urine Output
Total Input: ml
Total Output: ml
Fever Chart:
Systemic Examination:
CARDIOVASCULAR SYSTEM
Inspection :
-Shape of chest: elliptical
-No engorged veins, scars, visible pulsations
Palpation :
-Apex beat can be palpable in 5th intercostal space
- no cardiac thrills
Auscultation :
- S1,S2 are heard
- no murmurs
RESPIRATORY SYSTEM
Patient examined in sitting position
Inspection:
- Upper respiratory tract - oral cavity, nose & oropharynx appear normal.
-Chest appears Bilaterally symmetrical & elliptical in shape
- dyspnea if present
-Respiratory movements appear equal on both sides, abdominothoracic type (males).
-Trachea central in position & Nipples are in 5th intercoastal space
-No dilated veins, sinuses, visible pulsations.
Palpation:
-All inspiratory findings confirmed
-Trachea central in position
Percussion:
Resonant
Auscultation:
-Supraclavicular- (NVBS) (NVBS)
-Infraclavicular- (NVBS) (NVBS)
-Supramammary- (NVBS) (NVBS)
-Inframammary- (NVBS) (NVBS)
-Axillary- (NVBS) (NVBS)
-Infra axillary-(NVBS) (NVBS)
-Suprascapular- (NVBS) (NVBS)
-Interscapular- (NVBS)
-Infrascapular- (NVBS)(NVBS)
ABDOMEN
- abdominal girth : 38 inches
- shape: distended
- no tenderness
- no palpable mass
- no bruits
- no free fluid
- hernias orifices: normal
- liver: not palpable
- spleen : not palpable
- bowel sounds heard
- genitals:
- speculum examination :
- P/R examination :
CENTRAL NERVOUS SYSTEM
- conscious
- normal speech
- no neck stiffness
- no Kerning's sign
- cranial nerves: normal
- sensory : normal
- motor: normal
- reflexes: all present bilaterally
- finger nose in coordination: no
- knee heel in coordination: no
- gait: normal
Investigations:
Upper Gastrointestinal Endoscopy:
2D echo:
Hemogram + Total Proteins + Liver enzymes:
Provisional Diagnosis:
Decompensated chronic liver disease
Chronic alcoholic
Treatment:
TAB. LASILACTONE
TAB. LASIX
INJ. VIT K
TAB. RIFAGUT
TAB. UDILIV
SYRUP LACTULOSE
PROTIEN POWDER
