A 44 years male resident of miryalguda admitted with chief complain of bilateral pedal odema since 1 week

 Hi, I am Niteesh Gangina (roll no :81)3rd semester medical student. this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.

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 patients 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 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.  

CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.

A 44 years male resident of miryalguda admitted with chief complain of bilateral pedal odema since 1 week

Chief complaints 

C/O Abdominal discomfort tightness bloating sensation 2 years intermittent gradually progressive abdominal distension 

No C/O loss of appetite,Nausea,Vomiting

No C/O loose stools,nausea,vomiting

No c/o chest pain ,SOB,cough,cold

C/O fever low grade not chills and rigor aggravating at night

History of present illness

C/O Dark colour yellow urine

C/O weight gain 

H/O similar complaints in the past 2 years

 History of past illness

Diabetes - No

Hypertension -No

Heart disease - No

Stroke - No 

Concern - No

Tuberculosis-no

Asthma - No

Personal history

Occupation works in construction 

Diet:mixed

Appetite:normal

Sleep:normal

Consumes alcohol regularly daily 300 ml

No known allergies

FAMILY HISTORY 

Not significant 

General examination 

Patient is conscious,coherent and coperative.

Well built , moderately nourished and well oriented to time,place and person.

No pallor 

No icterus 

No cyanosis 

No clubbing of fingers

No lymphadenopathy 

 pedal odema is present

SYSTEMATIC EXAMINATION:

A.Vitals

Temperature: 100°C

PR: 90 bpm

RR:18 cpm

BP:140/90 mm Hg

SpO2: 97%

B. CARDIO VASCULAR SYSTEM

1. Thrills No 

2. Cardiac Sounds S1,S2 heard

3. Cardiac murmurs No 

C. RESPIRATORY SYSTEM

1. Dyspnoea - no

2. Wheeze - No 

3. Position of Trachea - Central

4. Breath Sounds - Vesicular

5. Adventilious Sounds - No

D. ABDOMEN

1. Shape of abdomen - Distended

2. Tenderness - yes

3. Palpable mass - No 

4. Hernial Orifices Normal 

5. Free Fluid yes

6. Bruits No 

7. Liver - Not palpable

8. Spleen - Not palpable 

9. Bowel sounds -Yes

10.Genitals normal

Central nervous system 

1.level of conscious conscious and covert

2.speech normal

3.sign of menningeal irritation

Neck stiffness no

Kerning sign no

Cerebral signs

Finger nose test in coordination 

Knee heel test in coordination 

Investigations 

Provisionals diagnosis: decomsated chronic liver disease

Treatment

Fresh Frozen Plasma 

First time

Second time

3 time

4 time