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General medicine final practical short case

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 patient's 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 the comment box"

50 year old male, farmer by occupation,  came to Medicine OPD with complaints of : 

* Distended abdomen since 7 days 
* Pain abdomen since 7 days
* Pedal edema since 5 days 
* Breathlessness since 4 days.
* Decreased micturition since 2 days.

HISTORY OF PRESENT ILLNESS: 

The patient was apparently asymptomatic 6 months ago when he developed jaundice and was treated at a private practitioner.

Later he developed abdominal distension about 7 days ago - insidious in onset, gradually progressive to the present size - associated with 

  • Pain in epigastric and right hypochondrium  
  • Not associated with fever , No night sweats.
  • Not associated with Nausea, vomiting, loose stools 


There was pedal edema ( grade 2 )

  • Gradually progressive 
  • Pitting type
  • Bilateral 
  • Below knees
  • Increases during the day - maximum at evening.
  • No local rise of temperature and tenderness 
  • Not relived on rest 

He also complained of shortness of breath since 4 days - MRC grade 4

  • Insidious in onset
  • Gradually progressive 
  • Aggravated on eating and lying down ; No relieving factors
  • No PND
  • No cough/sputum/hemoptysis
  • No chest pain
  • No wheezing


Patient is a known alcoholic since 20 years, he stopped taking alcohol since 6 months When he drank on 29/5/22 ascites has increased.


Daily Routine : 

Wakes up at 5am and goes to field.

Comes home at 8am and has rice for breakfast. Returns to work at 9am.

1pm - lunch

2-6 pm - work

6pm - home

8pm - dinner

Alcohol- 2 times a week, 180 ml.

PAST HISTORY: 

No history of similar complaints in the past 

Medical history- not a known case of DM, HTN, TB, Epilepsy, Asthma, CAD

Surgical history - not significant 


PERSONAL HISTORY: 

  • Diet - mixed
  • Appetite- reduced since 7 days
  • Sleep - disturbed
  • Bowel - regular
  • Bladder - oliguria since 2 days, no burning micturition, feeling of incomplete voiding. 
  • Allergies- none
  • Addictions - Beedi -4 - 5/day since 30 years ;

                           - Alcohol - Toddy - 1 bottle, 2 times a week, since 30 years;

                                           - Whiskey-180 ml, 2 times a week, since 5 years.

                                           - Last alcohol intake - 29th May, 2022.


FAMILY HISTORY:

Not significant 


GENERAL EXAMINATION: 

Patient is conscious, coherent and co-operative.

Examined in a well lit room.

Moderately built and nourished


Icterus - present (sclera)

Pedal edema - present - bilateral pitting type, grade 2                  No pallor, cyanosis, clubbing, lymphoedenopathy.




Vitals : 

Temperature- afebrile

Respiratory rate - 16cpm

Pulse rate - 101 bpm

BP - 120/80 mm Hg.


SYSTEMIC EXAMINATION: 


CVS : S1 S2 heard, no murmurs

Respiratory system : normal vesicular breath sounds heard.


Abdominal examination: 

INSPECTION : 

      Shape of abdomen- distended

  • Umblicus - everted
  • Movements of abdominal wall - moves with respiration 
  • Skin is smooth and shiny;
  • No scars, sinuses, distended veins, striae.


PALPATION : 

Local rise of temperature present.

Tenderness present - epigastrium.

Tense abdomen 

Guarding present

Rigidity absent 

Fluid thrill positive 

Liver not palpable 

Spleen not palpable 

Kidneys not palpable 

Lymph nodes not palpable 


PERCUSSION: 

Liver span : not detectable 

Fluid thrill: felt 

Tympanic note is heard on the midline and dull note is heard on the flanks in supine position


AUSCULTATION: 

Bowel sounds are decreased 


CNS EXAMINATION: 

Conscious 

Speech normal

No signs of meningeal irritation 

Cranial nerves: normal

Sensory system: normal

Motor system: normal

Reflexes:      Right.           Left. 

Biceps.         ++.                 ++

Triceps.         ++.                 ++

Supinator      ++.                  ++

Knee.              ++.                 ++

Ankle              ++.                  ++


Gait: normal


INVESTIGATIONS: 


Serology: 

HIV - negative 

HCV - negative 

HBsAg - negative 




PROVISIONAL DIAGNOSIS:

Decompensated chronic liver disease with ascites.


TREATMENT: 

Inj Lasix 40 mg iv BD

Tab spironolactone 50 mg BD

Paracentesis

Syp. Lactose 15ml TID

Abdominal girth charting - 4th hourly

Fluid restrictriction less than 1L per day

Salt restriction less than 2 gms per day

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