45 M with Abdominal distension and b/l lower limb swelling

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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.

Unit 1 

AMC bed 5

DOA:29/5/23

45 year old male ,lorry driver by occupation,resident of Nalgonda came to the opd with chief complaints of 

     Abdominal distension since 4-5 days

     Abdominal bloating since 4-5 days

     Shortness of breath since 4-5 days

     Vomitings since 3 days

     B/L lower limb swelling since 15-20 days

HOPI :

he was apparently asymptomatic 15 days back then he developed swelling of both lower limbs (extending up to knee ,pitting type)insidious in onset ,gradually progressive, no aggravating and relieving factors .

Abdominal distension since 5 days ,insidious in onset ,gradually progressive,no aggravating and relieving factors Associated with bloating ,SOB and vomitings 

No h/o chest pain ,orthopnea ,PND,palpitations 

No h/o deceased urine output,burning micturition ,fever 

Past history 

K/c/o DM since 4-5 years on medication Tab Metformin 500mg po BD 

N/k/c/o HTN CVA CAD TB EPILEPSY 

H/o Alcoholism since 10 years aggrevated 4 yrs back (180ml per day)

Personal history:

Diet :mixed 

Appetite:normal 

Bowel and bladder:regular 

Sleep: adequate

Addictions:chronic alocoholic since 10years

No known allergies 

Family history:not significant

General examination:

She is conscious,coherent , cooperative 

Well oriented to time ,place and person 

Pallor present 

Icterus present

Edema present

Vitals:

Temp:101.5F

Bp:130/70mmofhg

PR:119bpm

RR:20cpm

Grbs:mg/dl

No clubbing ,cyanosis, lymphadenopathy

CVS:s1s2+,no murmur

RS:BAE+,no added sounds 

P/A: 

Inspection;

Shape of abdomen; distended 

Position of umbilicus: central and inverted

No scars and sinuses are present

All quadrants are moving equally with respiration

Palpation:

No tenderness 

No organomegaly

Auscultation:

Bowel sounds heard 

CNS: NFD

Investigations 

ECG 

2D ECHO

CXR

USG FINDINGS 

Treatment:

Inj.pan 40mg IV/OD 

Inj.thiamine 200mg in 100ml Ns /IV /TID

Inj.zofer 4mg/IV/TID

Inj.lasix 20mg IV/OD