45/M with Abdominal distension and pedal edema

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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 : 

      

Chest X-ray: 

           

Ultrasound abdomen: 

         

2D ECHO: 

      

Ascitic fluid : 

 

      

Provisional diagnosis: 

CLD with portal hypertension 

Treatment: 

1)Tab Lasix 80 mg po OD 

2)Tab Aldoctone  50mg BD

3)Tab Lactulose 20ml ODHS