49 yrs old female with abdominal distension and pedal edema

A 49 YEAR OLD MALE CAME WITH ABDOMINAL DISTENSION AND PEDAL EDEMA.CASE SHEET:

Chief complaints:

A 49 year old male, driver by occupation came to causality with chief complaints of:
- Abdominal distention since 10 days
- pedal edema since 10 days

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic 20 years back. At age of 10, he developed seizures, which subsided itself without any medication.

10 years back, patient has scaly lesions on hands and legs for which he was diagnosed as psoriasis. Since then he was on regular medication.

A year back, the patient has yellowish discoloration of sclera for which he used herbal medicine for 6 days. Again after 3 months, he had similar case of yellowish discoloration of sclera for which he used herbal medicine for 7 days.

He had yellowish discoloration for 20 days and distention of abdomen for 10 days and pedal edema for 10 days.

ASSOCIATED DISEASES:

No significant diseases.

PAST HISTORY:

The patient was a known case of psoriasis 20 years back.

PERSONAL HISTORY:

Diet: Mixed
Bowel : constipation since 20 days
Micturition: Burning micturition 
Appetite: Decreased
Habits: Regular alcoholic since 7 years
No history of allergy, asthma, tuberculosis, coronary artery disease.

FAMILY HISTORY:

No significant family history.

DRUG HISTORY:

No significant drug history

GENERAL EXAMINATION:

No pallor
No cyanosis
No clubbing
No lymphadenopathy
No malnutrition
No dehydration
Icterus present
Pedal edema 
VITALS:

Temperature: 98.4 F

Pulse: 89 beats per minute

Respiratory rate: 16 cycles per minute

Blood pressure: 120/70 mm of Hg

SPO2: 99%

SYSTEMIC EXAMINATION:

Cardiovascular system:

No thrills
No murumurs
Cardiac sounds: S1, S2 heard

Respiratory system:

No dyspnea
No wheezing
Breath sounds heard: vesicular

Abdomen:

Shape: distended
No tenderness
No palpable mass
Non palpable liver
Non palpable spleen
No bruits
Bowel sounds: heard

Central Nervous System:

Conscious
Speech: normal

INVESTIGATIONS:
Biochemical investigations

Treatment-
TAB: LASIX 40mg po/td
TAB: SPIRINOLACTONE 100mg po/od
TAB: UDILIV 300mg po/bd
TAB: RIFAGUT 550mg po/bd
SYRUP: LACTULOSE 30ml po/td
INJ: VITAMIN K (amp) 100 ml iv/od
PROTIENEX POWDER IN 100ml of milk po/td
TAB: PANTOP 40mg po/od
 BENZAC- AC GEL - od (face) 2 weeks
MOISTUREX SOFT LOTION - (body) 2 weeks
TAB: VIBOLIV 500mg po/bd
TAB: MAXILIV 500mg po/bd
TAB: ANTIOXID po/od
E/D: LUBREX 5 times/day
TAB: PREDNISOLONE 20mg po/odPROVISIONAL DIAGNOSIS:
Chronic liver disease.

Comments

Post a Comment

Popular posts from this blog

final exam long case

Image
This is an online elog book to discuss our patients de-identified health data shared after taking his/her/guardians signed informed consent.Here we discuss our individual patients 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 elog book reflect s my patients centered online portfolio and your valuable inputs on the comments is welcome.    Chief complaint -  A 54 yrs old male patient of resident suryapet, shop keeper by occupation came to opd with chief complaint of pedal edema from 1 month and fever from 4 days.  History of present illness- Patient was apparantly asymptomatic 6months months back and then he developed  fever   associated with chills , rigor and vomitings. He was admitted in local hospital and was found to have raised creatinine levels and diagnosed as renal failure. He was under observation for 10days and treated . He was on
Read more

a 45 yrs old male patient

Image
 A patient who is 45 yr old male came to OPD with chief complaints of fever since 2 days and slurring of speech since 1 day and pain in both lowerlimbs . HISTORY OF PRESENT ILLNESS     Patient is a daily wage worker by occupation . Patient was apparently asymptomatic 2 years back then his appetite increased( about 5- 6 times a day ) for which he came to KIMS hospital and diagnosed with Diabetes.He used oral hypoglycemic drugs for first 6 months.Then from past 1.5 years he is on insulin.He was a chronic alcoholic since 25 yrs. He consumes more than 180ml / day . Urine output increased since 2 years about 10 times a day.Decreased weight about 25kg since 2 years. Then since 2 days he developed fever which was high grade, continuous and associated with chills and rigor and also presence of neck stiffness and burning Micturition.Patient was also anemic for which he received blood transfusion   He developed slurring of speech since 1 day then he came to hospital the next day HISTORY OF PA
Read more

27 yr old male patient with Acute gastro enteritis

Image
 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 a series of inputs available global online community of experts with the aim to solve the patient’s clinical problems with the collective current best evidence based inputs. This E log reflects my patient centred online learning portfolio and your valuable inputs in the comments section. 27 year old male came to OPD with complaints of fever for 5 days, abdominal discomfort since 5 days, nausea, vomiting ,loose stools since 5 days, burning micturition since 3 days.  Patient was apparently asymptomatic 5 days back who works as a car driver since 5 years who was occasional Toddy drinker ( 1 glass of intake for any occasional festival )  5 days ago he went to function where he consumed 1 litre of Toddy along with red meat , following next day he experienced pain abdomen which was squeezing
Read more