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This is an a online e log book to discuss our patient 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 problem with collective current best evident based input.

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

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

 55 YEAR OLD MALE PATIENT WAS BROUGHT TO CASUALTY WITH COMPLAINTS OF 

SCROTAL SWELLING SINCE 15 DAYS

FEVER SINCE 15 DAYS

COUGH WITH SPUTUM SINCE 15 DAYS

YELLOWISH DISCOLORATION OF EYES SINCE 15 DAYS

SHORTNESS OF BREATH SINCE 15 DAYS

 

HISTORY OF PRESENTING ILLNESS 202358574

PATIENT WAS PERFECTLY ALRIGHT 6 MONTHS BACK WHEN HE DEVELOPED ABDOMINAL DISTENSION WHICH WAS INSIDIOUS ONSET, GRADUALLY PROGRESSIVE , ASSOCIATED WITH SHORTNESS OF BREATH AND BILATERAL PEDAL EDEMA,NOT ASSOCIATED WITH PAIN, NO AGGREVATING AND RELIEVING FACTORS.

H/O MELENA PRESENT 

HE WAS THEN DIAGNOSED WITH CHRONIC LIVER DISEASE , ENDOSCOPY WAS DONE WHICH SHOWED GRADE 2 ESOPHAGEAL VARICES. ASCITES WAS MANAGED BY THERAPEUTIC TAPPING.( AROUND 8 LITRES OF ASCITES FLUID WAS TAPPED)

SINCE 15 DAYS,HE DEVELOPED BILATERAL SCROTAL EDEMA , GRADUALLY PROGRESSIVE ASSOCIATED WITH DRAGGING TYPE OF PAIN , LOCAL RISE OF TEMPERATURE AND REDNESS PRESENT.

HISTORY OF FEVER ASSOCIATED WITH PRODUCTIVE COUGH 

-NO H/O HEMATEMESIS , BLEEDING PER RECTUM, CONSTIPATION.

NO HISTORY OF HTN,DIABETES ,ASTHMA,EPILEPSY,CAD,CVA

 

PERSONAL HISTORY:

DIET:MIXED

SLEEP:ADEQUATE

BOWEL AND BLADDER:REGULAR

ADDICTIONS:NO

APPETITE:NORMAL

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE,WELL ORIENTED TO TIME,PLACE AND PERSON.

PALLOR PRESENT

NO ICTERUS CYANOSIS,CLUBING,LYMPHADENOPATHY,EDEMA.

VITALS:

TEMPERATURE:98.6

BP:110/70 MM HG

PR:80 BPM

RR:18 CPM

SYSTEMIC EXAMINATION:

CVS:S1,S2 HEARD NO MURMURS.

RS:BAE +, CREPTS PRESENT IN BILATERAL INFRA AXILLARY AND MAMMARY AREAS

PER ABDOMEN: 

UNIFORMLY DISTENDED

NON TENDER

SHIFTING DULLNESS PRESENT 

NO FLUID THRILL

CNS:NO FOCAL NEUROLOGICAL DEFICITS.

TREATMENT 

FLUID RESTRICTION <1.5L/DAY

SALT RESTRICTION <2GM/DAY

2-3 EGG WHITE PER DAY

INJ AUGMENTIN 1.2 GM IV TIDX 5 DAYS

INJ AZITHROMYCIN 500MG IV TID X5 DAYS

THERAPEUTIC TAP OF ASCITIC FLUID WAS DONE ON 1/4/24 ARIUND 1 LIT AND 3/1/24, AROUND 1 1/2 LITRE

HEPATIC PROTEIN POWDER 2SCOOPS IN MILK TID

T UDILIV 150MG OD MORNING

T INDERAL 20MG OD HS AT NIGHT

T OROFER XT BD M/N

T BENFOMET 100MG OD AFT

T DYTOR PLUS 10/50 OD MORNING

SYP LATULOSE 20ML TID