A 50Y/M with b/l pedal edema and abdominal distension

A 50 YEAR OLD MALE TRACTOR DRIVER BY OCCUPATION PRESENTED WITH

CHIEF COMPLAINTS:

Bilateral pedal edema since 3 months .

Abdominal distension since 15 days .

Itchy lesions on left hand and around head since 6 years.


HOPI:

Patient was apparently asymptomatic 3 months ago then he developed bilateral pedal edema insidious in onset & gradually progressive in nature, pitting type and extending upto knee joint.Then patient developed abdominal distension since 15days insidious in onset and gradually progressive in nature , no history of shortness of breath,chest pain,vomitings,hematemesis,dark colored stools,pain abdomen. No history of fever , cough , burning micturation, decreased urine output.

H/O itchy lesion with hyperpigmented lesion on left hand and around head since 6 years (on & off).H/o exposure to occupational work with chemicals.

PAST HISTORY:


K/C/O HTN since 3 years on T.Telvas-H 40/12.5 PO/OD . Stopped medication 6 months ago.

Not k/c/o DM/CVD/EPILEPSY/TB/ASTHMA.

PERSONAL HISTORY:

Appetite-Normal

Diet - Mixed

Bowel and bladder - regular 

Sleep - Normal.

General examination:

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

Pallor - absent

Icterus - absent 

Cyanosis - absent 

Clubbing - absent 

Lymphadenopathy- absent 

Pedal edema - pitting type extending till knee 



VITALS:
        Temp - 96.8F
         PR - 66 bpm
         RR - 18 cpm
         BP - 110/80 mm/hg 
         SPO2 - 97% at RA
         GRBS - 102 mg/dl
Systemic examination: 

PER ABDOMEN:
Inspection :
    Umbilicus is central and inverted
    All quadrants are moving equally with respiration 
    No scars , sinuses , engorged veins, visible pulsations .
    Hernial orifices are free.
Palpitation :
     Abdomen is soft and tenderness present in right hypochondrium
     No organomegaly.
Percussion :
    Tympanic note heard over the abdomen.
Auscultation:
    Bowel sounds are heard.

CARDIOVASCULAR SYSTEM:
Inspection:
       Shape of chest is elliptical.
        No raised JVP
        No visible pulsations, scars , sinuses , engorged veins.
Palpitation:
        Apex beat - felt at left 5th intercostal space
        No thrills and parasternal heaves
Auscultation :
        S1 and S2 heard. 
RESPIRATORY SYSTEM:
Inspection: 
    Shape- elliptical 
     B/L symmetrical , 
     Both sides moving equally with respiration .
     No scars, sinuses, engorged veins, pulsations 
Palpation:
    Trachea - central
     Expansion of chest is symmetrical. 
     Vocal fremitus - normal
Percussion: 
      Resonant bilaterally 
Auscultation:
      Bilateral air entry present. Normal vesicular breath sounds heard.

CENTRAL NERVOUS SYSTEM:
      Conscious,coherent and cooperative 
      Speech- normal
      No signs of meningeal irritation. 
      Cranial nerves- intact
      Sensory system- normal 
 
Motor system:
      Tone- normal
      Power- bilaterally 5/5
     Reflexes    Right    Left
     Biceps         ++         ++
     Triceps        ++         ++
     Supinator    ++       ++
     Knee            ++       ++
     Ankle           ++        ++
















DIAGNOSIS:


DECOMPENSATED LIVER DISEASE WITH PORTAL HYPERTENSION WITH ASCITES WITH HYPERTENSION SINCE 3 YEARS


TREATMENT:


1)SALT RESTRICTION <1.2gm/day

2)FLUID RESTRICTION <2lit/day

3)TAB.RIFAXIMINE 400mg PO/BD

4)TAB.LASIX 40mg PO/BD

5)TAB.SPIRONOLACTONE 25mg PO/OD

6)SYP.LACTULOSE 15ml PO/TID











Comments

Post a Comment

Popular posts from this blog

INTERNSHIP ASSESSMENT

Image
  INTERNSHIP ASSESSMENT: Posted in department of GENERAL MEDICINE from 12/12/22 to 11/2/23. PSYCHIATRY POSTING:(from 12/12/22 to 26/12/22) Learned about importance of history taking and how to reach to provisional diagnosis through history taking. Seen different patient in op: 1.Schizophrenia 2.Alcohol Dependence Syndrome 3.Tobbaco Dependence Syndrome 4.OCD 5.Panic attack 6.Psychosis Learnt medications given to the patients and their side effects. Learnt about audit score - a parameter used in evaluating alcohol dependence. UNIT DUTIES: 27/12/22 to 26/1/23 In OP: Took brief history of patients, done systemic examination. Ordered necessary investigations according to the symptoms. Learnt to pescribe medications according to symptoms of the patient. In Unit: Drawn venous blood samples,collected reports of samples sent. Updated fever chart everyday.Updated reports in unit group and investigations charts. Got ECG,2D echo and xray done for the patients admitted under the unit. Initiated and
Read more

A 65Y/M with complaints of SOB

Image
This is a 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 patients problems through series of inputs from available global 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 in comment box is welcome.   A 65 years old Man Who is Resident of Narketpally who was Alcohol ( Sara ) Seller & Shepherd by Occupation Came with C/O  Fever Since 3 Days  HOPI :  At 10 years of Age Patient Was apparently Asymptomatic Till 10 years of Age & Once day He Climbed & Fell Down While Cutting Tree leaves for feeding Their Goats & Had a Fracture of Lt.Forearm & Went to Nalgonda District Hospital where Cast was applied & After 20 days He developed infection & a part of Bone was Protruded out &
Read more

A 22yr old primigravida...

Image
CASE REPORT :: A 22 year old primigravida with gestational age of 10 weeks who is housewife who is a resident of munugodu was brought with  CHIEF COMPLAINTS : Muscle spasms involving both upper ,  lower limb and neck since yesterday evening.  PAST HISTORY :: Not a known case of DM, HTN, Tuberculosis , asthma. No history of blood transfusion and major surgeries. PERSONAL HISTORY : Appetite :normal Diet : mixed  Sleep : adequate  Bowel and bladder : regular  No addictions. No known drug and food allergies. FAMILY HISTORY : No history of epilepsy in the family. GENERAL EXAMINATION : Patient is conscious coherent cooperative and well oriented to time place and person. Consent of the patient and attenders was taken and examined in a well lighted room. Patient is moderately built and nourished.  Pallor -  Present   Icterus - absent  Cyanosis - absent  Clubbing - absent Lymphadenopathy - absent Edema - absent VITALS  : Temperature : afebrile  Pulse rate - 78 beats per minute , normal rhythm a
Read more