A 53 yr old male with yellowish discolouration of eyes since 1month,abdominal distension since 20 days
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 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-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've 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 a diagnosis and treatment plan.
A 53 year old male came to the GM OPD with
CHIEF COMPLAINTS :
Yellowish Discolouration of eyes since 1 month
Abdominal Distension since 20 days
Pedal Edema since 20 days
Loss of appetite since 10 days
Cough, Fever since 5 days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently alright 1 month back then he had yellowish discolouration of eyes gradually progressive.
Abdominal Distension since 20 days, insidious in onset, gradually progressive.
Pedal edema since 20 days, pitting type upto knee
Fever since 5 days, low grade, more at night and associated with dry cough.
No h/o blood in stools, haemetemesis, abdominal pain
No h/o SOB, chest pain, palpitations
PAST HISTORY:
N/k/c/o DM2, HTN, TB, Epilepsy, CVA, CAD
PERSONAL HISTORY:
Appetite-Normal
Diet- Mixed
Bowel& Bladder - Mixed
Sleep- Adequate
Alcoholic since 40 yrs 90ml /day stopped 2months back
10 cigarettes/day for a year and stopped smoking 1 year back
GENERAL AND PHYSICAL EXAMINATION:
Patient C/CC
No Pallor, cyanosis, clubbing, lymphadenopathy
Icterus Present
Bilateral Pedal Edema Present
Vitals
Temp- Afebrile
PR-92bpm
BP-100/70 mmhg
RR-19cpm
Systemic Examination
CVS- S1 S2 +
CNS- NFND
RS- BAE +
P/A- Distension+
Shifting Dullness+
Fluid Thrill absent
Clinical images:
PROVISIONAL DIAGNOSIS-
Chronic Liver Disease
TREATMENT-
Tab. Furosemide + Aldactone 40/50 PO/OD
Tab. Riifaximin 550 mg PO/OD
Tab. Ursodepxycholic acid 300 mg PO/BD
Syp. Lactulose 15 ml PO/OD
Syp. L-Ornithine L-Aspartate PO/OD
Comments
Post a Comment