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

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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.

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 


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