1801006065-SHORT CASE
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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE 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
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.
HISTORY OF PRESENT ILLNESS:
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 of diabetes , hypertension , asthma, TB, epilepsy
He has a H/o liver infection 1year ago which had got relieved with medication.
TREATMENT HISTORY:
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:
PROVISIONAL DIAGNOSIS:
INVESTIGATIONS:
SAAG:
Serum albumin : 2.1 g/dl
Ascitic albumin : 0.22 g/dl
SAAG: 1.79
Ascitic fluid protein sugar :Total Bilirubin-4.75mg/dl
Direct Bilirubin-2.11mg/dl
SGOT(A ST)-70IU/L
SGP T(ALT)-50IU/L
ALKALINE PHOSPHATASE-200IU/L
TOTAL PROTEINS -6.2g/dl
ALBUMIN-2.01g/dl
A/G ratio-0.48
FBS- 143mg/dl
PLBS- 217mg/dl
USG and 2D echo was done
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