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45/M with Abdominal distension and pedal edema


45/M with Abdominal distension and pedal edema


This is 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 patients 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 comment box is welcome .



I’ve 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.


Case: 
45 year old male complaints of abdominal distension and b/l pedal edema (pitting type) , shortness of breath and scrotal swelling 

Chieftain complaints

Patient complaints of 
Abdominal distension 
B/l pedal edema 
Shortness of breath 
Scrotal swelling 
           Since 25 days 

History of presenting illness

Patient was apparently asymptomatic 6 years  back then he had c/o multiple swellings over chest for which he went to hospital and was diagnosed as diabetic and started starting medication since then 
2 years back when he went for routine checkup he was diagnosed as hypertensive and started taking medication 
6 months back patient became unresponsive and speech was reduced and was taken to local hospital where he was found to have low Grbs (27mg/dl ) and also found to have jaundice and was advised to stop alcohol consumption 
Then 25 days back he developed scrotal swelling   , pedal edema (pitting type ) above knee and abdominal distension which was insidious in onset and gradually progressive 
He also c/o sob on exertion since 20 days which progressed now 

Past history 
K/c/o HTN on tab telma 40mg since 2 years 
K/c/o DM since 6 years used tab glibenclamide 5mg + metformin 500mg 
Stopped taking medication since 6 months 


Family history 

Insignificant 

Personal history 

Diet; mixed 
Appetite; normal 
Sleep; adequate 8 hrs per day
Bowel ; regular 
Bladder; regular 
Addictions; chronic alcoholic since 20years -360ml 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  
Weight : 
BMI: 
Abdominal girth: 124cm 
Vitals; 
Temp: afebrile 
Pulse rate: 90bpm
Respiratory rate: 22
BP: 130/80
SpO2:98
Pallor, cyanosis, clubbing, are absent 
Edema-pedal( pitting)
Icterus present 



             



                 


           



       



          


          


           

           




Systemic examination 

CVS: s1 s2 heard no murmurs present 
Respiratory: bilateral normal vesicular breath sounds are present 
CNS: no neurological deficit’s are present 
Abdominal examination:
Inspection: 
Abdominal distension 
Umbilicus everted 
Engorged veins present 
No visible peristalsis 
No scars , sinuses 
Palpitation:
Soft non-tender 
no hepatomegaly or splenomegaly 
Bowel sounds heard 
Percussion : 
Fluid thrill present 
Shifting dullness 



Investigations

Hemogram: 

On 27-10-22:
       
         

On 29-10-22: 

         




APTT:


Blood urea:


Serum electrolytes: 

On  27-10-22:


On 29-10-22: 

         



LFT: 

On 27-10-22: 


On 29-10-22: 

       


PT:



CUE:


Serum creatinine:



SAAG: 
        

Ascitic fluid amylase: 


Ascitic fluid LDH: 


 
Ascitic fluid protein sugar : 

      






           



Ultrasound abdomen: 

         


2D ECHO: 

      





 

      


Provisional diagnosis: 
CLD with portal hypertension 

Treatment: 

1)Tab Lasix 80 mg po OD 
2)Tab Aldoctone  50mg BD
3)Tab Lactulose 20ml ODHS

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