A 46 year old male with Ascites

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Hi, This is Vijaya Ratna,5th sem medical student.This Elog depicts the patient centered approach to learning. This is an online eLogbook recorded to discuss and comprehend our patient's deidentified health data shared, after taking his/her/guardian's signed informed consent.
**This is an ongoing case.I am in the process of updating and editing this Elog as and when required**

Date of admission : 27/07/2022

A 46 year old male patient, farmer by occupation, resident of nalgonda came with chief complaints of 
1. Shortness of breath since 6 years
2.Cough since 4 years (on and off)
3. Pedal oedema and facial puffiness since 3 years.
4. Abdominal distension since 3 years. 
5. Hard stools since 10 days. 

HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 6years ago. Then developed shortness of breath which was initially grade 1 and gradually progressed to grade 3 .
Cough since 4 years (on and off) which is productive with yellow colored sputum. 
3 years back - Developed Abdominal distension , pedal oedema and  puffiness so visited a hospital in miryalaguda 2years back and got relieved on medication for few days but again he developed abdominal distension, facial puffiness and pedal oedema. 
Hard stools since 10 days. 

EXTENDED HISTORY
He wakes up at 5AM in the morning and works in the animal shed like cleaning the shed, and does his breakfast at 10AM and goes to herd his sheeps and comes back home at 6PM,skips his lunch and have his dinner at 9PM in the night and goes to sleep at 10PM.

HISTORY OF PAST ILLNESS
Not a known case of HTN, DM, TB, epilepsy, CAD.

PERSONAL HISTORY
Marital status : Married 
Occupation : Shepherd and farmer
Diet : mixed
Appetite : Normal
Sleep : not adequate
Bowel movements : irregular (hard stools since 10 days)
Micturition : normal
Addictions 
Alcohol : Regular since 30 years (stopped drinking since April 2022) 
Tobacco : smoking (1 pack of cigarette /day)
He has no known Allergies. 

TREATMENT HISTORY
Cataract surgery was done 1 year ago in left eye.

FAMILY HISTORY 
No significant family history. 

DRUG HISTORY
Not Significant

GENERAL EXAMINATION
Patient is conscious , coherent , cooperative and examined in a well lit room. 

VITALS
Pulse Rate: 88/min
Blood pressure:130/70mmHg
Respiratory rate: 
Temperature : 98.6°F
Spo2 : 98%
GRBS : 205mg%

PHYSICAL EXAMINATION 
Pallor : absent 
Icterus : absent
Cyanosis : absent
Clubbing of fingers and toes : absent 
Lymphadenopathy : absent
Edema : Bilateral pitting type of Pedal oedema present
Malnutrition : absent
Dehydration : absent

SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
S1 and S2 are heard 
No thrills
No murmurs

RESPIRATORY SYSTEM
INSPECTION
Wheeze heard
Pectus excavatum type of chest
No scars and sinuses 
Trachea central
PALPATION
Inspectory findings are confirmed
Palpable sounds seen
PERCUSSION
Resonant note present in all lung areas
AUSCULTATION 
Rhonchi is heard
Crepts are present 

PER ABDOMEN
INSPECTION
Distended shaped abdomen
Umbilicus everted
Movements with respiration-
Caput medusae seen


PALPATION
NO Tenderness in any quadrants of abdomen, liver and spleen.
Liver and spleen -
No palpable mass
PERCUSSION
Shifting dullness - present
Free fluid - absent
No bruits
AUSCULTATION
Bowel sounds : present

CNS 
Conscious
Speech : Normal
No signs of meningeal irritation
Cranial nerves : intact
Motor system : Normal
Sensory system : Normal
Reflexes : Normal

INVESTIGATIONS
                 ULTRASOUND 
ECG
27/7/2022
HEMOGRAM
LIVER FUNCTION TEST
BLOOD UREA
SERUM CREATININE
SERUM ELECTROLYTES
BLOOD SUGAR FASTING
BLOOD SUGAR RANDOM
GLYCATED HEMOGLOBIN
POST LUNCH BLOOD SUGAR

28/7/2022
HBsAg ELISA
HIV 1/2 ELISA
Anti HCV Antibodies 
29/7/2022
APTT
PROTHROMBIN TIME
PROVISIONAL DIAGNOSIS
Chronic liver disease ??with Right Ventricular Heart failure
Chronic bronchitis??

TREATMENT
27/7/2022
INJ. LASIX 40mg IV/BD
Neb. Duolin 8th hourly
Neb. Budecort 8th hourly

28/7/2022
Inj. Lasix 40mg IV/BD
Neb. Duolin 8th hourly
Neb. Budecort 12th hourly
Tab. Azithromycin 500mg PO/OD
Tab. Montac LC /PO/OD
Tab. Metformin 500mg PO/OD

29/7/2022
Inj. Lasix 40mg IV/BD
Neb: Duolin 8th hourly
Neb: Budecort 12th hourly 
Tab. Azithromycin 500mg PO/OD
Tab. Montac LC PO/OD
Tab. Metformin 500mg PO/OD

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