40M WITH BLOATING AND YELLOWISH DISCOLORATION OF EYES.
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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.
Radhesh Mahankali.
48 year old male resident of Chityala Auto Driver by occupation
CHIEF COMPLAINTS
Abdominal distension since 20 days
Breathlessness since 20 days
Swelling of bilateral lower limbs since 20 days
Decreased urine output since 3 days
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 20 days back then he developed abdominal distension which was insidious in onset ,gradually progressed to present size . It is diffuse type of abdominal distension
H/o Shortness of breath since 10 days initially he used to walk to his home without any problem after parking his auto at a distance from home.Now he has to take rest after walking such distance (MMRC grade 2) .Distension doesn’t change with position
No h/o orthopnea ,PND,abdominal pain ,vomitting ,obstipation .
Swelling of bilateral lower limbs since 15 days insidious in onset , gradually progressive upto knee level, pitting type (grade 2) reduced on walking ,no change at rest and raising the legs
No history of chest pain ,palpitations,facial puffiness .
H/o high coloured urine since 20 days associated with decreased urine output since 10 days not associated with burning micturation,pain ,increased frequency and urgency .
H/o yellowish discolouration since 2 years not associated with itching ,pale coloured stools .
No H/o fever ,headache ,rash ,joint pains ,no history of change in sleep pattern ,confusion ,altered sensorium ,no history of blood in stools, melena ,constipation .
PAST HISTORY
History of two hospitals visits in past two years
History of generalised weakness ,abdominal distension two years back ,diagnosed to have chronic liver disease.
Received rehabilitation,Abstained from consuming alcohol for 1 year
Starting consuming alcohol ,followed by an Episode of jaundice 1 year back with similar complaints of Generalised weakness ,abdominal distension
K/C/O HTN since 10 years
Not a K/C /O DM,TB,seizures ,heart diseases,thyroid abnormalities,
No history of blood transfusions,tattooing , chronic drug intake .
FAMILY HISTORY
No similar complaints in the family
TREATMENT HISTORY
T.Telma 80mg initially
Later was put on T.telma 40mg
T.amlong 5 mg currently
Atenolol 50 mg currently
PERSONAL HISTORY
Diet -mixed
Appetite -decreased
Sleep -adequate
Bowel and bladder -regular ,reduced output
Addictions -alcoholic since 13 years
Consumes 250-350 ml of whiskey everyday
GENERAL PHYSICAL EXAMINATION
Patient is conscious,coherent and co operative
patient is moderately nourished and moderately built
Weight -48kgs
PALLOR -absent
ICTERUS -present involving the upper bulbar conjunctiva
CYANOSIS -absent
CLUBBING -absent
LYMPHADENOPATHY -absent
PEDAL EDEMA -present
Head to toe examination:
hair is normal
No parotid swelling
Palmar erythema- absent
Gynaecomastia -absent
Pale coloured nails -present
Tremors -absent
spider naevi -absent
Petechiae,purpurae -absent
abdominal scars - present (ascitic tap )
VITALS
TEMP - afebrile
HEART RATE -78bpm
RESP RATE -18cpm
Per abdomen:no scars
Inspection:
Abdomen is distended
flank are full
Umbilicus is everted
skin is normal
no discolouration of skin ,engorged veins ,sinuses amd spider naevi
No visible peristalsis or pulsations
Palpation:
No local rise of temperature
No tenderness
No guarding
No Rigidity
No organomegaly
Percussion
Liver
upper border of liver dullness is per used at the right 6 th inter coastal space along the mid -clavicular line on full expiration and the lower border cannot be palpated
Spleen
Castell’s method - dullness is observed in 9 th ICS of any axillary line
fluid thrill +ve
Shifting dullness +ve
Auscultation
bowel sounds heard
CVS examination
Inspection :
Shape of chest- elliptical
No engorged veins, scars, visible pulsations
JVP - raised
Palpation :
Apex beat can be palpable in 5th inter costal space
No thrills and parasternal heaves can be felt
Auscultation :
S1,S2 are heard
no murmurs
RESPIRATORY SYSTEM:
Inspection:
Shape- elliptical
B/L symmetrical ,
Both sides moving equally with respiration .
No scars, sinuses, engorged veins, pulsations
Palpation:
Trachea - central
Expansion of chest is symmetrical.
Vocal fremitus - reduced on left side in mammary ,axillary and infraxillary areas
Percussion: stony dullness in left in left mammary ,axillary ,infraxillary areas
Tidal percussion-resonant note
Auscultation:
bilateral air entry present. Normal vesicular breath sounds heard
PROVISIONAL DIAGNOSIS
Decompensated Chronic liver disease.
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