A 50 yr old man with ascites...

FINAL EXAMINATION CASE REPORT

NAME: D.Santhosh

Hall ticket no: 1701006036

Batch: 2017

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50 year old male, farmer by occupation, resident of Pochampally, came to Medicine OPD with complaints of :

* Distended abdomen since 7 days

* Pain abdomen since 7 days

* Pedal edema since 5 days

* Breathlessness since 4 days.

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic 6 months ago when he developed jaundice and was treated at a private practitioner.

Later he developed abdominal distension about 7 days ago - insidious in onset, gradually progressive to the present size - associated with

Pain in epigastric and right hypocondrium - colicky type.
Fever - high grade, not associated with chills and rigor, decreased on medication, No night sweats.
Not associated with Nausea, vomiting, loose stools

There was pedal edema

Gradually progressive
Pitting type
Bilateral
Below knees
Increases during the day - maximum at evening.
No local rise of temperature and tenderness
Grade 2
Not relived on rest

He also complained of shortness of breath since 4 days - MRC grade 4

Insidious in onset
Gradually progressive
Agrevated on eating and lying down ; No relieving factors
No PND
No cough/sputum/hemoptysis
No chest pain
No wheezing

Patient is a known alcoholic since 20 years. Ascites increased after his last drink on 29th May, 2022.

Daily Routine :

Wakes up at 5am and goes to field.

Comes home at 8am and has rice for breakfast. Returns to work at 9am.

1pm - lunch

2-6 pm - work

6pm - home

8pm - dinner

Alcohol- 2 times a week, 180 ml.

PAST HISTORY:

No history of similar complaints in the past

Medical history- not a known case of DM, HTN, TB, Epilepsy, Asthma, CAD

Surgical history - not significant

PERSONAL HISTORY:

Diet - mixed
Appetite- reduced since 7 days
Sleep - disturbed
Bowel - regular
Bladder - oliguria since 2 days, no burning micturition, feeling of incomplete voiding.
Allergies- none
Addictions - Beedi - 8-10/day since 20 years ;

- Alcohol - Toddy - 1 bottle, 2 times a week, since 20 years;

- Whiskey-180 ml, 2 times a week, since 5 years.

- Last alcohol intake - 29th May, 2022.

FAMILY HISTORY:

Not significant

GENERAL EXAMINATION:

Patient is conscious, coherent and co-operative.

Examined in a well lit room.

Moderately built and nourished

Icterus - present (sclera)

Pedal edema - present - bilateral pitting type, grade 2 - https://youtube.com/shorts/Uwz_0gxzqUM?feature=share

No pallor, cyanosis, clubbing, lymphoedenopathy.