A 45year old male with ascites

 

THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT 

 

Chief complaints :

A 45 year old male who is a resident of Nalgonda and Sheperd  by occupation presented to the opd with chief complaints of  shortness of breath and  cough since 6 years abdominal distention , facial puffiness , pedal edema since 3 years.

HOPI

patient was apparently asymptomatic 6 year back and then he developed shortness of breath which is insidious in onset gradually progressive which is initially grade 2 then progressed to grade 3 .

Then he developed cough which is productive with sputum which is yellow in colour and non blood stained 

There is history of abdominal distention since 3 years which is insidious in onset and gradually progressive  then he consulted a local doctor and used medications but then its not relieved and continued to progress  for which he came here .

He also has  history of  facial puffiness and pedal edema for  which he is  on medications .

History of constipation since 1 year .

No history of vomiting , fever, jaundice , orthopnoea , PND, chest pain , palpitations , weight loss.

DAILY ROUTINE:

He wakes up in the morning by 6'o clock and goes to the work by 9'o clock  after having breakfast  and  he will have his lunch by 1 in the afternoon and continues with the work then he goes back to home by 6 pm in the evening .

PAST HISTORY:

No similar complaints in the past 

Not a known case  diabetes , hypertension , asthma, TB, epilepsy 

He has a H/o liver infection 1year ago which had got relieved with medication.

Treatment history:

Right IOL implantation in 2021

Family history:

Not relevant

Personal history:

Diet : mixed 

Appetite-normal

Sleep-inadequate 

Bowel and bladder movements-constipation since 1year,urine output is normal

Addictions-He had H/o alcohol intake since his childhood and abstinence of alcohol from 1year

H/o smoking since childhood  18 cigars per day

GENERAL EXAMINATION:

Patient is conscious,coherent,cooperative and well oriented to time and place.

Moderately built and nourished

Bp:130/70 mm/hg

PR:88/min

RR: 17 cpm

Temperature: afebrile 

HR: 74 bpm

Pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy:absent

Pedal edema: B/L pedal edema is present

Spo2: 96%

GRBS: 205 mg/dl

Systemic examination:

CVS: S1,S2 heard ,no murmurs

RS: Grade 3 dyspnoea,expiratory wheeze is present

Patient examined in sitting position

Inspection:-

oral cavity- Normal ,nose- normal ,pharynx-normal 

Shape of chest - funnel chest(Pectus excavation)

Chest movements : bilaterally symmetrically reduced

Trachea is central in position.

Palpation:-

All inspiratory findings are confirmed

Trachea central in position

Apical impulse in left 5th ICS, 

Chest movements bilaterally symmetrical 

AUSCULTATION 

BAE+,  NVBS

Abdomen:

Abdominal distention present

Umbilical hernia is present (everted umbilicus)

Fluid thrill is absent but there shifting of dullness

No tenderness and no palpable mass

Bowel sounds are heard

Liver and spleen are not palpable

 

 

RECTI DEVARICATION: 

CNS:

No focal neurological deficits

Investigations:

Provisional diagnosis:

Ascites

Chronic liver failure? 

Treatment:

-Inj.lasix 40mg/kg/BD

-Nebduolin 8th hrly

   Budicon 12th hrly

-Monitor vitals

-Tab.Azithromycin 500mg po/OD *3days

-Tab.Montek - hc po/OD *3days

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