1601006152 SHORT CASE

 

1601006152

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 series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment.


Short case 

   A 53yrs old male patient farmer by occupation hailing from Nakrekal came with the chief complaints of Shortness of breath since 4months 


History of present illness

Patient was asymptomatic 4 months back then he developed distension of abdomen, shortness of breath which is present at rest (grade 4) and he also developed jaundice for which he visited a hospital in Hyderabad there he was diagnosed with liver disease. He was treated for one month in the hospital and all his symptoms were relieved 

After 1 month after relief from symptoms he drank alcohol after which he developed shortness of breath and distension of abdomen for which he was treated again and medication were given


At present he has shortness of breath of grade 3 

No history of chest pain 

No history of palpitations 

No history of orthopnea and PND

No history of cough

Past history 

He was diagnosed with diabetes mellitus 3months back and is under medication 

Not a known case of hypertension, bronchial asthma, tuberculosis 

Personal history 

Diet: mixed

Appetite: normal 

Sleep :adequate 

Bowel and bladder movements: regular 

He is an alcoholic since 30years.

Family history 

No history of similar complaints in family 

No history of diabetes mellitus, hypertension, bronchial asthma

General examination

Patient is conscious coherent and cooperative moderately built and moderately nourishment 

Vitals

Temperature: Afebrile

Pulse: 80bpm

Respiratory rate: 20cpm

BP: 110/70mmHg

Icterus is present

Pallor is absent

Clubbing :absent

Cyanosis: absent

Koilonychia: absent

Edema: absent


Abdomen examination

Inspection: 

Abdomen is distended

Umbilicus is central

All quadrants are moving with respiration

No sinus and engorged veins 





Palpation

No local rise of temperatures and tenderness 

Hepatomegaly is present 

Splenomegaly is present

Percussion 

Fluid thrill and shifting dullness is absent

Auscultation

Bowel sounds are heard


Investigations

Complete Blood Picture



Liver function test




Ultrasound Abdomen


Provisional diagnosis 

Since patient has shortness of breath, , abdominal distension and hepatosplenomegaly my anatomical diagnosis is liver

After performing investigations diagnosis is confirmed as chronic liver disease with portal hypertension 

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