48 yr old male with abdominal distension and fever

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 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 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.



Patient came with the complaints of abdominal distension since 4 days and fever since 10days.

Patient was apparently asymptomatic 10days back then he developed  fever  evening rise of temperature low grade not associated with chills and rigors relieved on medication. Abdominal distension since 4 days associated with 1 episode of vomiting after food intake, food as content  not associated with pedal edema, facial puffiness, burning sensation.

No H/O chest pain, breathlessness, palpitations, cough, cold.

H/O lower back pain and  burning micturation on and off, no change in colour.

H/O loss of appetite, loss of weight.


Past history: n/k/c/o Dm, htn,asthma thyroid abnormalities.


Personal history

Diet is Mixed, Appetite is normal, Bladder and bowel are movements regular, Sleep is adequate

No Allergies, No Addictions.


General examination:

Patient is conscious coherent and cooperative well oriented to time place and person. He's moderately built and nourished.






Edema - Abdominal edema

Pallor, Icterus, Cubbing, Cyanosis, Lymphadenopathy- Absent 

VITALS-

Temperature afebrile

Respiratory rate 18cpm

Pulse rate 78bpm

Blood pressure 110/70mmHg

Spo2 97%


CVS- S1 S2 heard, No added murmurs.

RS- Normal vesicular breath sounds

CNS - No focal neurological deficit.

P/A- Inspection Abdominal distension seen with, dull note on percussion, bowel sounds heard.


INVESTIGATIONS:





Ascitic fluid cell count 50cells - 100%neutrophills











Ascitic diagnostic tap was done 









Review usg on 4/1/24





PROVISIONAL DIAGNOSIS-

Gross Ascites 2 to NAFLD

B/L renal calculi.


TREATMENT:

T NEUROBION PO/OD

T LASIX 20MG PO/BD

Syp CREMAFFIN 20ML PO/BD


DAY 2






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