A 60 year old male with abdominal distention














 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 solveb 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.


Case:
A 60 year old male with Abdominal distension since 3 months

History of presenting illness:
Patient was apparently asymptomatic until 3 months ago He then he complained of abdominal discomfort which was Sudden gradually progressive accompained with Bloating Sensation and tightness; 
SOB aggreviated after having food
History of similar complaints 3 months ago and ascitic tap was done.
c/o loss of appetite.
H/o Lower abdominal pain 5 months ago. 
No Clo Decreased or Increased urine output, Burning Mictuntion 
No c/o chest pain, orthopnea; PND; Sweating; Palpitations 
No clo Cough, Cold. 
No c/o loose stools,Constipation,Nausea,Vomitings

Past history 
H/o Jaundice 2 years ago. used Herbal Medication.
Not a k/c/o DM,HTN,TB,Asthma,Epilepsy

Personal history: 
Diet:mixed
Appetite: adequate 
Bowel and bladder: regular
Addictions: patient was an occasional alcoholic from the age of 20 years and from the age of 40 he has been a regular alcoholic. 
He drinks local sara but stopped 5 months back.

General examination: Patient is conscious,coherant and cooperative,moderately built and moderately nourished.

Pallor present
No icterus
No cyanosis
No clubbing 
No lymphadenopathy
No pedal edema

Vitals: 
Temperature: afebrile
Pulse rate: 70 bpm
Blood pressure: 110/70 mm Hg
Respiratory rate: 18cpm








Systemic examination:
CNS: no focal neurological Deficits
CVS: S1 and S2 are heard
Respiratory: bilateral air entry is present
Abdomen: abdomen distended,soft and non tender. Shifting dullness present and bowel sounds are heard


Investigations:














Provisional diagnosis:
Chronic decompensated liver disease with portal hypertension
Ascites and spleenmegaly present
?Chronic hepatits B positive
?hepato renal syndrome 

Treatment:
FLUID RESTRICTION 1.5L day
Salt restriction less than 2grams/day
 TAB. ALDACTONE 50mg per oral OD
Tab lasix 20mg per oral BD
Protein powder 2 scoops in a glass of milk per oral BD
Daily abdominal girth monitoring
Vital monitoring 4th hourly.
.





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