A 44 YR OLD MALE C/O B/L PEDAL OEDEMA SINCE 6 MONTHS, ABDOMINAL DISTENSION SINCE 6 MONTHS ,COUGH WITH OUT EXPECTORIATION SINCE 4 DAYS
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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 44 YR OLD MALE CAME TO OPD WITH COMPLAINTS OF B/L PEDAL OEDEMA SINCE 6 MONTHS, ABDOMINAL DISTENSION SINCE 6 MONTHS ,COUGH WITH OUT EXPECTORIATION SINCE 4 DAYS
PATIENT WAS APPARENTLY ASYMPTOMATIC 6 MONTHS AGO THEN HE DEVELOPED B/L PEDAL EDEMA PITTING TYPE INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE NO AGGREVATING AND RELIEVING FACTORS
ABDOMINAL DISTENSION SINCE 6 MONTHS INSIDIOUS ONSET GRADUALLY PROGRESSIVE INITIALLY SMALL IN SIZE AND PROGRRESSED TO PRESENT SIZE
PT INITIALLY WENT TO OUT SIDE HOSPITAL AND DIAGNOSTIC TAP WAS DONE (NO DOCUMENTS AVAILABLE) THEN DISCHARGED WITH MEDICATION (LASIX)
COUGH WITH OUT EXPECTORIATION SINCE 4 DAYS NO AGGREVATIMG AND RELIEVING FACTORS
NO H/O CONSTIPATION, BURNING MICTIRITION, NAUSEA, VOMITING
NO H/O FEVER, COUGH, BREATHLESSNESS, LOOSEMOTIONS, CHEST PAIN, PALPITATIONS, ORTHOPNEA, PND
NO H/O DM, HTN, ASTHMA, TB, EPILEPSY, CVA,CAD,CKD
PERSONAL HISTORY OCCUPATION AUTO DRIVER
ALCOHOL INTAKE DAILY SINCE 20 YRS 1LT PER DAY
CIGERETTE SMOKING
EXAMINATION
PT IS C/C/C
NO PALLOR ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY OEDEMA IN FEET
TEMP AFEBRILR
PR 86bPM
RR 18CPM
BP 110/80 MMHG
ABDOMINAL EXAMINATION:
INSPECTION:
SHAPE - DISTENDED
FLANKS-FULL
UMBILICUS - INVERTED
ALL QUADRANTS MOVES EQUALLY WITH RESPIRATION
NO ENGORGED VEINS, VISIBLE PULSATIONS,SCARS,SINUSESRS,SINUSESRS,SINUSES
PALPATION:
ALL INSPECTORY FINDINGS ARE CONFIRMED
NO LOCAL RISE OF TEMPERATURE
ABDOMEN IS SOFT AND NON TENDER
SPLEEN AND LIVER -NOT PALPABLE
NO OTHER PALPABLE MASES
HERNIAL ORIFICE ARE FREE
PERCUSSION:
SHIFTING DULLNESS PRESENT
FLUID THRILL PRESENT
AUSCULTATION:
BOWEL SOUNDS HEARD
CVS S1 S2 +NO MURMUR
RESPIRATORY SYSTEM B/L AE+
GASTRO REFERAL DONE ON 9/1/24
IMPRESSION GRADE 1 ESOPHAGEAL VARICES
LOW GRADE PORTAL HYPERTENSION
Usg abdomen
Diagnostic and therapeutic Ascetic tap done
https://youtube.com/shorts/a8o-PbkIxfc?si=N0h9bbD2XUrR9FSs
Investigation s
Ascitic fluid findings on day 1
Ascitic fluid findings on day 2
Electronic discharge
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