Gen med elog

 

35YR MALE WITH C/O ABDOMINAL SWELLING

This is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed 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 .


A 35 year old male house contractor by occupation from Miryalaguda came to general medicine OPD with chief complaints of swelling in feet and abdomen since 2days 
Tingling sensation,cought since 1 week , difficulty in intake of food.

History of presenting illness: 
Patient was apparently asymptomatic 2days back then he developed edema in lower limbs  which is  insidious in onset gradual in progression  and pitting type? and then he developed
 swelling in abdomen insidious  onest gradual progression
h/o nausea ,tiredness and tingling sensation after eating food 
No h/o vomiting, pain abdomen
H/o cough non productive type , because of cough he was having discomfort in food and water intake while swallowing. 


Past history:
2 months back patient had distended abdomen feet  swelling went to local hospital there he had tingling sensation and numbness hiccups also then   they kept  him in ICU for 3 days ,later he was referred to Kims  
He was adviced for weekly checkup 
N/K/C/O : Diabetesmellitus, Asthma , epilepsy, thyroid disorders, Hypertension 


Personal history:
Patient now wakes up at 4 am , then 
Have breakfast dosa , because of tingling sensation after food intake , he preferred not to eat anything 
In evening he drinks  jawa 
Appetite is reduced 
consumed mixed diet 
Sleep  disturbance since 2 years  wakes up during sleep sometimes  sleeps for 4 to 5 hrs and watches tv if he don't get sleep
Bowel  and bladder movement are  regular 
Addiction for  alcohol intake since 10 years intitially once a week and then it became 4 to 5 times a week of 1 quarter every time 
 (stopped from 2 months ) 









1/12/23













Treatment history using lasix and lactulose syrup 

General Examination:
 Patient is conscious and coherent cooperative 
Vitals 
Temperature 
Pulse rate:
Respiratory rate:
GRBS:
spo2
Pallor-
Icterus
No cyanosis,clubbing, edema -
Head and neck - 
No alopecia   
 Trunk- genecomastia present in right breast
Abdominal distention present  
No loss of axillary hair ,No dilated veins 

Palmar erythema -?


Systemic examination 
CVS - S1, S2 heard 
RS - BilateralAirEntry + , NVBS 
P/A -
- SHAPE OF ABDOMEN - OBESE 
- ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION.?
NO SCARS AND SINUSES 
HERNIAL ORIFICES ARE FREE.
- BOWEL SOUNDS +?
CNS
CRANIAL NERVES EXAMINATION - NORMAL
SENSORY SYSTEM- INTACT
MOTOR SYSTEM EXAMINATON - NORMAL 
REFLEXES - 

FINGER NOSE COORDINATION - PRESENT
KNEE HEEL COORDINATION - PRESENT 

PROVISIONAL DIAGNOSIS 

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