58M with abdominal pain and distension

 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 box is welcome."

 

CHIEF COMPLAINTS -58-year-old male came to the general medicine OPD with the chief complaints of abdominal distension and stomach pain

HOPI-Patient was apparently asymptomatic 12 days back when he developed abdominal pain and progressively increasing abdominal distension patient complained of decreased appetite and was taken to the hospital in oligonda thinking that it was acidity and was given tablet pantop, a tonic[ unknown medication], his abdominal distension kept progressing and did not resolve with medication in view of this he was brought to our general medicine OPD.

PAST HISTORY -patient is a known case of chronic kidney disease and osteoarthritis of wrist ,knees and metatarsals 

PERSONAL HISTORY-patient is a 58-year-old male resident of BhopalaPeta a labourer by occupation married since 38 years with three kids all of them being boys, 

Appetite

patient complains of decreased appetite since past 10 days, 

Bowel and bladder movements

dribbling urination ,bowel movements are normal ,

Addictions 

patient is a regular consumer of alcohol he consumes whiskey ,Sara,smokes Bhidi for more than 40 years now . 

Patient had consumed a little more than two glasses of alcohol which is more than his usual consumption (2glasses) 13 days back .

Family history- No significant family history

GENERAL EXAMINATION - GENERAL EXAMINATION 

patient is semiconscious, drowsy ,semi coherent and coperative 

VITALS 

BP-120 /70 mmhg 

PR -88bpm, regular 

RR-22cpm

TEMP -98 celcius 

SpO2-92 percent at room air 

Systemic examination

CVS 

On palpation

Apex beat was felt in the 5 th inter coastal space medial to the mid clavicular line 

Jvp was normal 

No precordial bulge 

No parasternal heave 

-S1,S2 heard no murmurs 

RS-

On inspection 

Chest is b/l symmetrical 

Expansion of chest equal on both sides 

Position of trachea -central 

No visible scars sinuses 

On palpation 

Expansion of chest was equal on both sides 

Position of trachea -central 

Tactile vocal fremitus -was felt 

On percussion 

all lung areas resonant 

On auscultation

BAE + ,wheeze present 

Vocal resonance - all areas resonant 

PER ABDOMEN -ovoid, distended

Umbilicus -Inverted 

bowel sounds - heard 

Decreased  movements in all quadrants with respiration

No visible pulsations, peristalsis, dilated veins and local swelling

PALPATION

SUPERFICIAL -localised guarding and rigidity present ,no local rise of temperature.

DEEP- spleenomegaly present 

Percussion 

fluid thrill and shifting dullness present 

puddle sign  present

AUSCULTATION 

Bowel sounds present

No local lymphadenopathy 

CNS -

All cranial nerves are intact functioning 

Motor system examination 

Normal bulk in upper and lower limbs 

Normal time in upper and lower limb

Normal power in upper and lower limb 

Gait is normal 

Reflexes are normal 

Sensory examination 

Normal sensations are felt in all the dermatomes 

NFND , HMF intact 

No cerebellar signs 

No meningeal signs 

INVESTIGATIONS 

USG ABDOMEN 

ASCITIC TAP WAS DONE TO COLLECT THE ASCITIC FLUID FOR SEROLOGICAL TESTING 

ECG 

ASCITIC FLUID COLLECTED 

  

-PATIENT TESTED POSITIVE FOR HBsAg.

HEMOGRAM 

11/11/2022

13/11/2022

LFT 

11/11/2022

12/11/2022

        

13/11/2022

RFT 

12/11/2022

13/11/2022

X-RAY CHEST AND ABDOMEN 

CUE

Provisional diagnosis -CKD with hepatitis B ,? Dengue fever 

TREATMENT 

IVF 1 DNS 

Inj neomol 1 gm I.v

Tab dolo 650 mg tid 

Inj pantop 40 mg I.v od

Inj  vitb12 1500 mcg in 100 NS over 1 hr.