A 65 Year Old Patient With SOB and Abdominal Distension and Swelling in Both Legs

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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.

Ankur Kumar

Roll no 14

CHIEF COMPLAINTS

C/O ABDOMINAL DISTENSION SINCE One and Half MONTH 

C/O B/L LOWER LIMB SWELLING SINCE One and Half MONTH 

C/O BREATHLESSNESS SINCE One MONTH 

HOPI

A  65 year Old Male  resident of Bhuvanagiri was brought to casualty on a wheel chair on 20 /12/22 with complaint of abdominal distension since one and half month gradually progressive not associated with pain.

H/O Bilateral lower limb swelling since One and half month.

H/O Shortness Of Breath of grade 2 to 3 MMRC Since a month which is insidious onset gradually progressive

 No H/O  chest pain,  

No H/O Decreased urine output 

No H/O PND

No H/O Orthopnea 

No H/O Fever

No H/O cough and cold 

No H/O breathlessness 

No H/O Day time sleepiness.

Now admitted for further management and treatment

Past history

Patient had breathlessness for which bought for consultation and diagnosed with HTN and DM 6 years back 

He is on medication 

1 Tab. amlodipine 5 mg po/od at 8 am 

2. Tab. glimipiride 2 mg + metformin 1000 mg po/ od at 8 am 

He is known case of CVA hemiplegia on rt side with deviation of mouth to left side 15 yrs ago 

Got treatment for 5 years - Resolved 

H/o head injury 30 yrs ago in a train accident pt had injury at occipital region of scalp followed by altered behaviour for 6 months and used treatment for 6 months and resolved 

H/o Right knee joint pain 5 yrs back.

PERSONAL HISTORY: 

Sleep - Decreased from 2 years 

Diet - Mixed 

Appetite - decreased 

Bowel and bladder movements : regular 

Addictions  : Alcoholic   

Started at  17 yrs daily 160 ml brandy till sep 2022 from 1 St oct 90ml 

Tobacco 

Started at 17 yrs  36 beedis / day till sep 22

Daily  1 beedi / day from 1 St oct 

Treatment history 

Blood transfusion 5 months ago 

Drug history 

T etophylline and T theophylline po/hs. Since 5 days

General examination

Pt. is conscious , coherent , cooperative

Vitals

BP 140/90 mmhg 

PR 90bpm RR 18

GRBS. 114   spo 2 95

Pallor - absent 

Icterus - absent

Cyanosis - absent 

Clubbing - present 

Lymphadenopathy : absent 

Edema : Present till knee level and of pitting type 

Per ABDOMINAL examination

INSPECTION 

Abdomen is DISTENDED with flanks full

umbilicus is central slit like

Peude orange type of skin 

No scars and sinuses 

No ENGORGED veins 

No visible pulsation

PALPATION : 

all inspectory findings confirmed 

No rise of temperature and tenderness 

No guarding and rigidity 

Organomegaly not able to elicit 

Abdominal girth was127cms 

At present 125 cms  at umbilicus

Weight was 100kg

PERCUSSION : 

Shifting dullness - Present 

Fluid thrills - negative 

Puddle sign cannot be elicited ,as pt is not cooperative 

:Abdominal girth 127 now 125 at umbilicus

Weight was 100kg

AUSCULTATION :

bowel sounds are heard

No bruits

CVS 

S1S2 +, no murmurs

Respiratory system

BAE + with b/l Ronchi 

CNS 

HMF intact 

Power   u/ l     l/l 

Rt.          5/5.  5/5

Lt.            5/5.  5/5 

Reflexes. 

                   Rt.         Lt

Biceps.      ++.        ++

Triceps.     +.            +

Supinat.    +.            + 

Knee.         _. Ve.     _ Ve 

Ankle.        _ Ve.      _. Ve 

Plantar.      F.             F 

No cerebellar and meningial signs 

INVESTIGATION S 

Urine culture and sensitivity 

No pus cells and polymicrobial flora grown 

Ascitic fluid cytology  

No cells  seen 

Ascitic culture and sensitivity 

No acid fast bacilli 

No pus cells and organism seen 

X ray 

Ecg 

Ultrasound abdomen

Gall bladder edema 

Liver. Coarse echotextire with irregular surface  

So chronic liver disease 

No IHBRD  

Gross ascites 

Diagnosis

CHRONIC DECOMPENSATED LIVER DISEASE WITH HIGH SAAG LOW PROTEIN ASCITES SECONDARY 

TO ALCOHOLIC LIVER DISEASE WITH B/L LOWER LIMB EDEMA GRADE 2 WITH HYPONATREMIA AND HYPOKALEMIA 

Treatment 

1 Inj. Lasix 40mg iv/od

2 T. Aldactone 50mg po/od

3 Syp. Lactulose 15ml po/tid 

4 Inj HAI s/c acc. To grbs 

5. Tab. Amlong 5mg po/od

6. Fluid restriction < 1.5L/day

7. Salt restriction < 2 g/day 

8 Therapeutic paracentesis

Soap notes

ICU bed no 4

S

Sob in lying down position

Stools passed

No fever spikes

O

O/e 

Pt. is c/c/c 

BP 140/90 mmhg 

PR 90bpm RR 18

GRBS. 114   spo 2 95

CVS S1S2 +

RS BAE + with b/l Ronchi 

P/A distended 

CNS HMF intact 

-A

Decompensated chronic liver disease(secondary to alcohol)

 with known case of diabetes and Hypertension 

P

1 Inj. Lasix 40mg iv/od

2 T. Aldactone 50mg po/od

3 Syp. Lactulose 15ml po/tid 

4 Inj HAI s/c acc. To grbs 

5. Tab. Amlong 5mg po/od

6. Fluid restriction < 1.5L/day

7. Salt restriction < 2 g/day 

8 Therapeutic paracentesis