45 yrs male with abdominal distention

June 02, 2023

45yrs old male with Abdominal Distention

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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 in brief:

Unit 1

AMC bed 5

DOA:29/5/23

45 year old male ,lorry driver by occupation,resident of Nalgonda came to the opd with

chief complaints of

- Abdominal distension since 4-5 days

- Abdominal bloating since 4-5 days

- Shortness of breath since 4-5 days

- Vomitings since 3 days

- B/L lower limb swelling since 15-20 days

HOPI :

He was apparently asymptomatic 15 days back then he developed swelling of both lower limbs (extending up to knee ,pitting type)insidious in onset ,gradually progressive, no aggravating and relieving factors .

Abdominal distension since 5 days ,insidious in onset ,gradually progressive,no aggravating and relieving factors Associated with bloating ,SOB and vomitings

No h/o chest pain ,orthopnea ,PND,palpitations

No h/o deceased urine output,burning micturition ,fever

Past history

K/c/o DM since 4-5 years on medication Tab Metformin 500mg po BD

N/k/c/o HTN CVA CAD TB EPILEPSY

H/o Alcoholism since 10 years aggrevated 4 yrs back (180ml per day)

Personal history:

Diet :mixed

Appetite:normal

Bowel and bladder:regular

Sleep: adequate

Addictions:chronic alocoholic since 10years