35 year old male patient resident of katamgur,toddy worker by occupation came with C/o distension of abdomen since 3 months, shortness of breath since 3 months.c/o pedal edema since 20 days.

This is 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 diagnosis and treatment plan.

35 year old male Patient  resident of katamgur, toddy worker by occupation came with C/o distension of abdomen since 3 months
C/o shortness of breath since 3 months 
C/o pedal edema since 20 days

HOPI:
Patient was apparently asymptomatic 6months back then he developed distension of abdomen with shortness of breath grade II , insidious in onset, gradually progressive,no aggravating and relieving factors.
C/o pedal edema since 20 days,B/L pitting type extending upto the knee.
C/o fever since 7 days on and off, associated with chills and rigors.
C/o chest pain since 7 days.
C/o decreased urine output since 20days
No c/o orthopnea,PND,chest pain, palpitations.
No C/o pain abdomen, vomitings,loose stools.
Patient had similar complaints in the past (6 months back), for which he got admitted in nalgonda hospital,stayed for about 11 days and then after being relieved.patient has continued doing the work . patient had similar complaints 14 days back for which he got admitted and not being relieved came for admission.
Past history:
K/C/O CLD
K/C/O T2 DM since 6 months and is on unknown medication.
H/o albumin transfusions done.
N/K/C/O HTN, EPILEPSY, ASTHMA,TB, THYROID DISORDERS 
Personal history:
Diet:mixed
Appetite: decreased
No significant weight loss
Decreased bowel and bladder movements
Sleep disturbed
No Tobacco addiction
Alcohol consumption since 20years , daily 50ml. Alcohol consumption is being stopped by the patient 6 months back due to similar complaints then he started consuming alcohol 3  months back, about 90ml daily.
Family history:
No  k/c/o HTN, EPILEPSY,ASTHMA,TB,DM, THYROID DISORDERS IN FAMILY 
Daily routine: 
before the onset of symptoms:
Patient used to wake up at 6am, went for toddy work and eat breakfast of rice and curry at 10am, at 2pm he used to have lunch and 3-7 pm he would go for toddy work,at 10pm patient used to have dinner.daily patient used to drink about 2-3times ,each time about 50ml.
After onset of symptoms:
Patient is unable to go to toddy work,sleeps daily and used to have breakfast at 10am of rice and curry and lunch at 2pm.he has a decreased appetite 

General examination:
Patient is Concious, coherent and cooperative well oriented to time place and person.
No  icterus, cyanosis, clubbing lymphadenopathy.
Pallor+
Pedal edema+

Temperature - 98.2F
PR- 84 bpm
BP- 120/80 mmHg
RR- 16 CPM
GRBS- 198 MG%
SYSTEMIC EXAMINATION -
CVS- S1,S2 + ,NO MURMURS 
RS- BAE+
CNS- NAD
PER ABDOMEN:
INSPECTION:
SHAPE OF ABDOMEN - DISTENDED
UMBILICUS -CENTRAL
NO SINUSES
SCARS+
PALPATION: 
TENDERNESS OVER THE PERIUMBILICAL REGION
NO PALPABLE MASS
HERNIAL ORIFICES- NORMAL
FREE FLUID - YES
LIVER - NOT PALPABLE
SPLEEN - NOT PALPABLE
PERCUSSION:
DULL NOTE ALL OVER THE ABDOMEN
AUSCULTATION:
BOWEL SOUNDS+



Diagnosis: CIRRHOTIC LIVER DISEASE ( STAGE III) T2 DM SINCE 5 MONTHS 
INVESTIGATIONS:
Heamogram:
Hb- #7.7
PCV- # 22.3
TLC- 5,000
RBC COUNT - # 2.36
PLATELET COUNT - 98,000
RBS- #194
BLOOD UREA- 14 
S.CREATININE -# 0.7
S.Na+ : #126
S.K+ :# 3.3
S Cl: #97
Prothrombin TC- 17
INR- 1.2
APTT- 35
LFT:
T.BILIRUBIN- #1.75
D.BILIRUBIN- #0.41
SGPT-11
SGOT- 27
Alkaline phosphate - #161
T.Proteins-#5.7
Albumin - 3.8
CUE:
Colour - pale yellow
RBC - nil
PUS CELLS- 3-4
SEROLOGY - NEGATIVE
TREATMENT:
1.FLUID RESTRICTION<2LIT/ DAY
2.SALT RESTRICTION<2 GM/ DAY
3.2 EGG WHITES/ DAY
4.PROTEIN POWER 2TBSP IN 1 GLASS OF WATER PO TID
5.T. SPIRONOLACTONE 25 MG PO/BD
6.STRICT INPUT/ OUTPUT CHARTING
7.BP,PR,RR, TEMPERATURE,SPO2 MONITORING 4TH HOURLY

Ascitic tap is being done on 28/7/23




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