1801006154 - LONG CASE 45 year old male with abdominal distension and pedal edema

 1801006154

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 available 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-centered online learning portfolio and your valuable inputs on the comment .

CASE:-

45 year old male complaints of abdominal distension and bilateral pedal edema (pitting type) , shortness of breath and scrotal swelling.

CHIEF COMPLAINTS:-

Patient complaints of

•Abdominal distension 

•swelling over both legs

•Shortness of breath 

•scrotal swelling 

  Since 25 days 

HISTORY OF PRESENTING ILLNESS:-

Patient was apparently asymptomatic 6 years ago, then he had swellings over chest for which he went to hospital and was diagnosed as diabetic and was on medication since then.

•2 years ago when he went for routine checkup he was diagnosed as hypertensive and was on medication .

•6 months back patient's speech was reduced for which he went to a local hospital where he was found to have low GRBS (27 mg/dl) and he

also had jaundice and was advised to stop consuming alcohol. 

•25days back he developed scrotal swelling, pedal edema, abdominal distension which was insidious in onset and gradually progressive, he also exhibited shortness of breath, for which he went to an RMP and was referred to KIMS, Narketpally.

• jaundice was present

• swelling of both legs was present.

PAST HISTORY:-

*History of Diabetes mellitus since 6 years and used tab.glibenclamide 5mg+ metformin 500mg, stopped taking medication since 6 months *History of hypertension since 2 years and taken Tab. Telma 40mg.

FAMILY HISTORY:- Insignificant.

PERSONAL HISTORY:-

•Diet:- mixed 

•Appetite:- normal 

•Sleep:- adequate 8 hrs per day

•Bowel and bladder :- regular

•Addictions:- ☆chronic alcoholic since 20years

                           -360 ml per day, stopped drinking since 1 month.

                       ☆ Chronic smoker since 30 years - 2 packs per day .

•Occupational history:-hotel owner 

GENERAL EXAMINATION:-

Patient is conscious, coherent and cooperative well oriented to time, place and person. 

•Height:-158cm  

•Abdominal girth: 124cm 

VITALS:-

•Temperature: afebrile 

•Pulse rate: 90bpm

•Respiratory rate: 22 cpm

•BP: 130/80 mmhg

•SpO2:98% 

Pallor present, icterus present,Edema- bilateral pitting edema,cyanosis, clubbing, are absent .

 

SYSTEMIC EXAMINATION:-

●ABDOMINAL EXAMINATION:-

☆Inspection: 

          Abdominal distended

           Flanks full

          Umbilicus everted , and displaced downwards.

          Engorged veins present 

         No visible peristalsis 

           No striae

          No scars , sinuses .

☆Palpitation:

Superficial palpation:-no tenderness, no warmth, blood flow in veins is away from umbilicus.

Deep palpation:-

          Soft non-tender 

           no hepatomegaly.

          Splenomegaly present.

          

     

              

☆Percussion :  Shifting dullness was present.Fluid thrill was present.

☆ Auscultation:- Bowel sounds heard, no venous hum and no splenic rub.

● CVS :- s1,s2, heard , no murmurs present.

●RESPIRATORY SYSTEM:- Normal vesicular breath sounds heard.

● CNS:- No focal neurological deficit seen.

INVESTIGATIONS:-

HEMOGRAM:-

Haemoglobin:- 10.4mg/dl

Total count     :-6600cells/cumm

Neutrophils    :-68%

Lymphocytes:-20%

Eosinophils     :-2%

Monocytes      :-10%

Basophils        :-0%

Pcv                    :- 31.5 volume%

Mcv                  :-114.1fl

Mch                  :-37.7pg

Mchc                :-33%

Rdw-cv            :- 15.6%

Rdw-sd            :-66.8fl

Rbc count       :- 2.76 millions/cumm

Platelet count:- 2 lakhs/cumm.

SMEAR:-

Rbc :- anisocytosis, with normocytes, macrocytes,               macroovalocytes seen

Wbc:- within normal limits

Platelets:-adequate in number and distribution

Hemoparasites:- no hemoparasites seen

Impression:- Dimorphic anemia

COMPLETE URINE EXAMINATION:-

Color     :- pale yellow

Appearance:- clear

Reaction:-acidic

Specific gravity:- 1.010( 1.001-1.035)

Albumin:- positive(+)

Sugars:- nil

Bile salts :- nil

Bile pigments:- nil

Pus cells:- 4-5/ hpf

Epithelial cells:- 2-4/hpf

Rbc :- nil

Crystals:- nil

Casts:- nil

Amorphous deposits:-absent

Others:- nil

PROTHROMBIN TIME:-

prothrombin time:-20 sec(10-16 sec)

INR:- 1.4

APTT:-

Aptt test:- 39 sec( 24 -33 sec)

BLOOD UREA:-

Blood urea:-49 mg/dl (12-42mg/dl)

SERUM CREATININE:-

serum creatinine:- 1.2mg /dl(0.9-1.3mg/dl)

LIVER FUNCTION TESTS:-

Total bilirubin:- 4.78mg/dl(0-1mg /dl)

Direct bilirubin:- 2.91mg/dl(0-0.2mg/dl)

SGOT(AST):- 104 IU/L(0-35 IU/L)

SGPT(ALT):- 50 IU/L (0-45IU/L)

ALP     :-260 IU/ L      (53-128IU/L)

Total proteins:-7.7 gm/dl(6.4 -8.3 gm/dl)

Albumin:- 2.4 gm/dl(3.5 -5.2 mg/dl)

A/G ratio:- 0.46

ULTRASONOGRAPHY ABDOMEN:-

ECG:-

Chest x ray:-

Doppler 2D -echo:-

DAY 2:-

Hb:-9.4

Tlc:- 7100

Rbc:- 2.5

Platelets:- 1.7 lakh

Total bilirubin:-3.41

Direct bilirubin:-2.21

AST:-74

ALT:- 36

ALP:-218

Total proteins:- 6.7

Albumin:- 2.0

A/G:- 0.45

Sodium:-139

Potassium:-3.9

Chloride:-105

DAY 3:-

Hb:-8.9

Tc:-14,600

Pcv:- 26.8

Mcv:-110.5

Mch:-36.9

Mchc:-33.4

RBc:- 2.4

Platelets :- 1.7 lakhs

LFT:-

Total bilirubin:- 3.43

Direct bilirubin:- 2.09

AST:- 70

ALT:- 31

ALP:-208

Total proteins:- 6.3

Albumin:- 2.0

A/G :- 0.45

DAY 4:-

LFT:-

Total bilirubin:- 3.38

Direct bilirubin:-1.68

AST:-59

ALT:-30

ALP:-193

Total proteins:-6.4

Albumin:- 2.61

A/G:- 0.46

Creatinine:-1.0

Sodium:-140

Potassium:-4.1

Chloride:-99

Calcium:-0.98

PROVISIONAL DIAGNOSIS:- 

Chronic liver disease  with portal hypertension and ascites.

TREATMENT: -

1.Tab Lasix 80 mg po once daily

2.Tab Aldactone  50mg twice daily

3.Tab Lactulose 20ml once daily before going to bed.