Skip to main content

A 60 yr old male with abdominal distension since 3 months

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' 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.

Case:
A 60 year old male with Abdominal distension since 3 months

History of presenting illness:
Patient was apparently asymptomatic until 3 months ago He then he complained of abdominal discomfort which was Sudden gradually progressive accompained with Bloating Sensation and tightness; 
SOB aggreviated after having food
History of similar complaints 3 months ago and ascitic tap was done.
c/o loss of appetite.
H/o Lower abdominal pain 5 months ago. 
No Clo Decreased or Increased urine output, Burning Mictuntion 
No c/o chest pain, orthopnea; PND; Sweating; Palpitations 
No clo Cough, Cold. 
No c/o loose stools,Constipation,Nausea,Vomitings

Past history 
H/o Jaundice 2 years ago. used Herbal Medication.
Not a k/c/o DM,HTN,TB,Asthma,Epilepsy

Personal history: 
Diet:mixed
Appetite: adequate 
Bowel and bladder: regular
Addictions: patient was an occasional alcoholic from the age of 20 years and from the age of 40 he has been a regular alcoholic. 
He drinks local sara but stopped 5 months back.

General examination: Patient is conscious,coherant and cooperative,moderately built and moderately nourished.

Pallor present
No icterus
No cyanosis
No clubbing 
No lymphadenopathy
No pedal edema

Vitals: 
Temperature: afebrile
Pulse rate: 70 bpm
Blood pressure: 110/70 mm Hg
Respiratory rate: 18cpm








Systemic examination:
CNS: no focal neurological Deficits
CVS: S1 and S2 are heard
Respiratory: bilateral air entry is present
Abdomen: abdomen distended,soft and non tender. Shifting dullness present and bowel sounds are heard


Investigations:














Provisional diagnosis:
Chronic decompensated liver disease with portal hypertension
Ascites and spleenmegaly present
?Chronic hepatits B positive
?hepato renal syndrome 

Treatment:
FLUID RESTRICTION 1.5L day
Salt restriction less than 2grams/day
 TAB. ALDACTONE 50mg per oral OD
Tab lasix 20mg per oral BD
Protein powder 2 scoops in a glass of milk per oral BD
Daily abdominal girth monitoring
Vital monitoring 4th hourly.
.






Popular posts from this blog

A 30 year male presented with c/o grade 4 SOB,fever-high grade

Image
CKD ON MHD 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' 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. Chief complaints: A 30 year male auto driver by occupation presented  2days ago with c/o grade 4 SOB,fever-high grade since 5days. HOPI: Patient was apparantly asymptomatic 1year back and then he developed  h/o intermittent chest pain and Sob ,and was diagnosed with diabetes and HTN 1 yr ago,on irregular medication and after that did not consult the doctor. Came to our hospital last month  with grade 4 SOB diagnosed with HFrEF,Renal failure with hypertension (?Cardiorenal) and  Dialysed in view of acute pulmonary edema 5 times last month,creat was 5.6 And then discharged on 2/6/2022 On Satu
Read more

CLD BLOGS.

https://rishikasrirollno20.blogspot.com/2023/04/a-60-year-old-male-with-abdominal.html  E yallaiah  https://aruna61.blogspot.com/2023/07/a-60yrm-chronic-alcoholic-with.html  venkatachari https://vijaykumarkasturi.blogspot.com/2023/03/45-year-male-with-sob-abdominal-swelling.html https://manogna33.blogspot.com/2022/11/44-year-old-male.html https://supriyakammari53.blogspot.com/2022/12/35yr-old-male-patient-with-abdominal.html https://makkenavarsha76.blogspot.com/2023/04/27yr-old-with-decompensated-liver.html https://chandanavishwanatham19.blogspot.com/2023/04/48-year-old-male-with-abdominal_22.html?m=1  k.yadagiri http://gayathrirollno22.blogspot.com/2023/04/35yr-old-with-yellowish-discolouration.html https://khyathiboyina24.blogspot.com/2023/05/45-year-old-male-with-decompensated.html http://tejasridevaruppala36.blogspot.com/2023/05/45-yr-old-male-with-abdominal.html https://ramyareddy105pebbeti.blogspot.com/2023/05/74year-old-female-with-abdominal.html https://harshzv.blogspot.com/202
Read more

A 45 yr old male came with complaints of abdominal distension ,sob and swelling in both legs since one week

Image
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 comments on 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. Presenting complaints: A  45 years old male,resindent of kodakonla mandal,janagam district hotel server by occupantion came with complaints of abdominal distension and shortness of breath
Read more