GENERAL MEDICINE BLOG

A 25 year old male, slab worker by occupation presented with shortness of breath and abdominal distension .

Hi, I am Mucha Sainath Reddy  , 3rd Sem Medical Student.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 box is welcome.”

I've 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 a diagnosis and treatment plan. 

Chief Complaints:

Patient came with the complaints of abdominal distension on and off for the past 3months.

He has shortness of breath grade II, which gradually progressed to grade III over 3 months.

HISTORY OF PRESENT ILLNESS:

Daily routine of the patient: Patient wakes up at 6:00 AM and completes his daily activities and goes to work.He carries heavy loads and then has a break in the afternoon. He says he consumes alcohol about 90-360 mL almost every day depending on how much money he has. He comes home around 9 and has dinner and sleeps.

At the age of 13years due to peer pressure he started consuming alcohol.

Patient was apparently asymptomatic 15years ago then started consuming alcohol,intially occasionally only in parties and festivals approximately 90ml which is gradually increased to 360ml/day.

After marriage patient experiences sleep disturbances, palpitations, headache, tremors, increased sweating, increased fearfulness of he doesn't consume alcohol.

Patient is consuming alcohol despite knowing it's harmful effects. Craving for alcohol is not present.

Patient started consuming tobacco 15years ago in the form of cigarette and chewing. Intially would chew 1 packet/day and 10 cigarettes/day which gradually increased to 2-3 packets/ day and 10-15 cigarettes/day.

Stopped chewing tobacco 1 year ago and stopped smoking cigarette 6months ago.

Presently smoking 1beedi/day. Patient experiences jaw pain, constipation if he doesn't smoke beedi.

PAST HISTORY:

He was diagnosed with jaundice 3 months ago.

He used herbal medication for 1 week for jaundice, abdominal distension,and fascial puffiness.

No Diabetes

No hypertension

No CAD

No asthma

No tuberculosis

No syphilis 

PERSONAL HISTORY:

Patient was married.

Diet: mixed

Appetite: lost

Bowels : regular 

Bladder: irregular

Sleep : adequate

Habits : chronic alcoholic and regular smoker

FAMILY HISTORY:

History of seizures in sister.

Alcohol and tobacco harmful use in father and mother.

ALLERGIEC HISTORY:

No known allergies.

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative.

Pallor is absent.

Icterus is present. No cyanosis, clubbing koilonychia, lymphadenopathy.

Pedal oedema present.

VITALS:

PR: 98 bom

RR: 22 cycles per minute

PO2: 98%

SYSTEMIC EXAMINATION:

Cardiovascular system:

No thrills 

No murmur 

Respiratory system:

Dyspnea is present

Wheeze: no

Abdomen:

Shape of abdomen: distended

 

INVESTIGATIONS:

Liver function tests:

Renal function tests:

 Ultrasound:

 2D echo:

 ECG:

X-ray: