45 years old male with abdominal distended and bloating since 5days
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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.
Unit 1
AMC bed 5
DOA:29/5/23
45 year old male ,lorry driver by occupation,resident of Nalgonda came to the opd with chief complaints of
BL lower limb swelling since 15-20days
Abdominal distension since 4-5 days
Abdominal bloating since 4-5 days
Shortness of breath since 4-5 days
Vomitings since 3 days
HOPI :
he was apparently asymptomatic 15 days back then he developed swelling of both lower limbs (extending up to knee ,pitting type)insidious in onset ,gradually progressive, no aggravating and relieving factors .
Abdominal distension since 5 days ,insidious in onset ,gradually progressive,no aggravating and relieving factors Associated with bloating ,SOB and vomitings non projectile, non bilious,
No h/o chest pain ,orthopnea ,PND,palpitations
No h/o deceased urine output,burning micturition ,fever
Past history
K/c/o DM since 4-5 years on medication Tab Metformin 500mg po BD
N/k/c/o HTN CVA CAD TB EPILEPSY
H/o Alcoholism since 10 years aggrevated 4 yrs back (180ml per day)
Personal history:
Diet :mixed
Appetite:normal
Bowel and bladder:regular
Sleep: adequate
Addictions:chronic alocoholic since 10years
No known allergies
Family history:not significant
General examination:
She is conscious,coherent , cooperative
Well oriented to time ,place and person
Vitals:
Temp:101.5F
Bp:130/70mmofhg
PR:119bpm
RR:20cpm
No clubbing ,cyanosis, lymphadenopathy
CVS:s1s2+,no murmur
RS:BAE+,no added sounds
P/A:
Inspection;
Shape of abdomen; distended
Position of umbilicus: central and inverted
No scars and sinuses are present
All quadrants are moving equally with respiration
Palpation:
No tenderness
No organomegaly
Auscultation:
Bowel sounds heard
CNS: NFD
Investigation
Ecg
Treatment:
Inj.pan 40mg IV/OD
Inj.thiamine 200mg in 100ml Ns /IV /TID
Inj.zofer 4mg/IV/TID
Inj.lasix 20mg IV/OD
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