GM case - 5
GM case - 5
March 7 ,2023
A 77 year patient came with a cheif complaint of difficulty in breathing, abdominal pain with bloating and abdominal distension.
My self Anu Bandlagudem of 3rd BDS .This is an online E log book to discuss our patients de- identified health data shared after taking her guardian's signed informed consent.Here we discuss our individual patients problem through series'of inputs from available global online community of experts with aim to solve those patients clinical problems with collective current best evidence based inputs.
I have been given this case to slove in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including history, findings, investigations, diagnosis and treatment plan.
Cheif complaint:
Difficulty in breathing since 3 days
Abdominal pain since 3 days
Abdominal distension since 3 days
History of present illness:
Patient is apparently asymptomatic before 3 days...he suddenly developed abdominal pain which is sudden and accompanied with abdominal distension with squeezing type of pain . Pain starting at epigastric region and towards umbilicus pain increased and shifting towards ileac region.Dyspnoea, decreased urine output, painful defecation , aggreviated after eating food.
No fever headache dizziness
No Pedel edema
No burning sensation in micturition
History of past illness:
Not a known case of Hypertension, Diabetes mellitus ,Asthama .
Known case of Tuberculosis.
Similar complaints 15 years ago.
15 yrs back - Empyema
3 yrs back - Analgesic abuse for knee pain
Liver - altered parenchymal echotexture
Cholecystitis
Grade 3 RPD changes Renal Cortical cysts
Personal history:
He is farmer and married.He woke up at 6 am and start his work till 8pm. He take 2 meals per day.
Diet- Mixed
Appatite - normal
Sleep - adequate
Bowel,- constipation
Micturition - decreased output
Addictions - Toddy
Family history:
No history is seen in his family
General examination:
Pallor- No
Icterus- No
Cyanosis-No
Clubbing- No
Lymphadenopathy- No
Edema- No
Jaundice - Yes
Vitals:
Temperature: afebrile
Bp- 130/ 80 mmHg
PR- 86bpm
Spo2 - 98%
Systemic examination:
CNS: Gait normal
CVS:S1S2 sounds heard
GIT:
Inspection:
Abdomen - Flanks full , distension
Umbilical hernia present
Appendectomy scar present
Palpation:
Done in supine postion with both limbs flexed and hands by side of the Body. Tenderness seen at hypochondiac region .
Liver not palpable
Spleen not palpable
No organomegaly
Fluid thrill present
Percussion:
Dull sound at near epigastric region and right hypocondrium.
Shifting dullness present.
Auscultation :
Normal bowel sounds heard.
Provisional diagnosis:
Ascites
Investigations:
Definitive diagnosis:
Ascites
Treatment:
Questions:
A patient who is non alcoholic can get this ascites ?? How and why??
Can this ascites fall on other systems functions???
