A 65 year old male with abdominal distension

4th April,2023

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. 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.

CHIEF COMPLAINTS :
-Abdominal distension since 3months
-Abdominal pain since 3 months

HISTORY OF PRESENTING ILLNESS:
-Patient was apparently asymptomatic 3months back,then he developed abdominal pain which was sudden in onset , gradually progressive in nature,started in the left hypochondriac region then involved whole abdomen,not a/w any aggravating or relieving factors 
-He also developed abdominal distension 3months back which was sudden in onset, gradually progressive and there are no aggravating or relieving factors.
-He complained of SOB which is of grade 3 according to MMRC scale.
-No h/o diarrhoea, vomiting, weight loss,dysphagia,hematemesis,anorexia.
-No h/o chest pain, cough,orthopnoea,palpitations.
-No h/o increased or decreased micturition and burning micturition.

PAST HISTORY:
-Similar complaints 3years back and were treated
-h/o jaundice 2years back and treated with herbal medication.
-ascitic tap done 2times in the past 3 months at regional hospital
-No h/o DM,HTN, epilepsy, tuberculosis
-No h/o any surgeries.

FAMILY HISTORY:
No similar complaints in the family

PERSONAL HISTORY:
Sleep-disturbed
Appetite -reduced
Bowel movements-3 to 4 times /day,green coloured
Bladder movements-regular
Addictions-
He is an alcoholic since 20 years then she stopped 3years ago,he again started consuming from 2 years but now he stopped temporarily since 3months due to present situation.


GENERAL EXAMINATION

Patient is conscious,coherent,cooperative and
he is malnourished.
Pallor - absent
Icterus-absent
Cyanosis-absent
Clubbing-absent
Lymphadenopathy-absent
Edema-absent


VITALS:-
Afebrile
PR-78bpm
RR-22cpm
BP-100/60mm Hg
SpO2-98%

SYSTEMIC EXAMINATION:

ABDOMINAL EXAMINATION -
INSPECTION:
 It is distended,flanks are full,umbilicus is central on the level of skin,movements of abdomen are equal and symmetrical and no visible gastric peristalsis.No scars,sinuses,dilated veins and hernial orifices are intact.
PALPATION:
No tenderness,no local rise in temperature
Liver and spleen are not palpable
No other palpable masses.
Abdominal girth- 87cm during inspiration
                               82cm during expiration
PERCUSSION:
Shifting dullness is present
Fluid thrill is absent
Liver span is 12cm
AUSCULTATION:
Bowel sounds- 8 to 9 per min
CVS :- S1 S2 heard and no murmurs heard 

RS :- BAE+ , NVBS heard, tracheal position is 
central 

CNS :- HMF present and no focal  neurological deficits are noticed.


PROVISIONAL DIAGNOSIS:
Ascites due to chronic liver disease?


INVESTIGATIONS:



TREATMENT:
Fluid restriction
Protein powder
Tab. Lasix
Tab. Aldactone
Tab. Udiliv
Tab. Benformet
Lactulose syrup



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