A 41 year old Male with stomach distension

   This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident 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.


A 41 year old male patient of suryapet came to OPD with chief complaints of  abdominal distension and SOB on eating or working ,speech distortion ,joint pains while walking.

CHIEF COMPLAINTS

Patient complains of abdominal distension since 7 days

shortness of breath since 7 days

unable to walk properly since 7 days.

HISTORY OF PRESENTING ILLNESS

Patient was asymptomatic until 1 week ago then developed abdominal distension with no pain and have speech disorientation and SOB.

constipation and reduced urinary output was seen.

PAST HISTORY

No similar complaints in the past

Not a know case of hypertension, diabetes.

PERSONAL HISTORY

Adequate diet before developing of symptoms

mixed diet

sleep no adequate

no consumption of alcohol and smoking

FAMILY HISTORY

No history is seen in family

No cases of hypertension and diabetes

TREATMENT HISTORY

Previously seen by a doctor and on prescribed medication no improvement is seen.

PHYSICAL EXAMINATION

GENERAL

Patient is cooperative and conscious.

proper nourishment and proper build is seen.

pallor     -yes

icterus    -yes

clubbing - absent

cyanosis - absent

edema    -yes

VITALS

BP- 100/80

PR-65/MIN

SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM-shortness of breath

CVS-S1,S2 +

RR- 16cpm

Spo2 -98%

ABDOMEN-ENLARGED/DISTENDED

CNS-SPEECH DISORIENTATION

INVESTIGATIONS






Treatment
1. Fluid restriction < 1 L / day
2. Salt restriction < 2gm / day
3.Tab Lasix 40mg /PO/BD
4. Tab. Aldactone 50mg/PO/BD
5.Abdominal girth & weight monitoring
6.Bp charting 6th hrly
7.GRBS charting 8th hrly 
8. Protein Powder with 100ml milk 


 

PROVINSIONAL DIAGNOSIS-LIVER AND KIDNEY FAILURE.


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