35M with pain abdomen and SOB

 This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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. 



A 35 yr male patient of carpenter in occupation and a resident of suryapet came to OPD with complaints of pain in the abdomen And SOB

CHEIF COMPLAINTS:

Pain in the abdomen since 3 months
Occasional palpitations since 3 months
shortness of breath since 1 month
Generalized weakness since 10 days

HOPI:

patient was asymptomatic 3 months ago then
Started developing palpitaions not associated with chest pain which is reduced on drinking alcohol. There is SOB which is of GRADE 1-2
Without association of orthopnea and PND
Pain is sudden  in onset, non radiating , no aggregating on consumption of food or during an activity, no releaving factors 

PAST ILLNESS:
generalized weakness since 10 days
Constipation is present 
No HISTORY of
Fever
burning micturation
Blood transfusions
N/K/C/O DM HTN asthma epilepsy TB CVA CAD
PERSONAL HISTORY:
Appitite normal
Bowel movements: abnormal
Bladder movements: normal
No allergies
Mixed diet
Addictions:
Alcohol (Chronic drinker consumes 750 ml of whiskey 16-19 units  daily since 20 yrs and sometimes 20-21 units on any occasions and functions with friends and daily after work about 6-7 units and had a habit of drinking toddy around 4-5 units a day  at the age of 15 for 3 years)
Tobacco (snuff)
FAMILY HISTORY: Non significant 

GENERAL EXAMINATION:
Patient is conscious co- operative and coherant
Moderately built
With 
Icterus  present 
 No pallor 
No lymadenopathy
No pedal oedema
No clubbing
No cynosis
VITALS
temp- febrile 99 degree F
Pulse -103bpm with normal volume and rhythm 
RR- 23
B.p- 110/70 spm
Spo2 - 94%
CVS EXAMINATION:
S1 AND S2 heared
No cardiac murmurs
Mild tachycardia is present 
ABDOMEN EXAMINATION:
inspection
Abdomen - distended
With no scars and surgical marks
Palpation : tenderness present all over the body but more in the right hypochondrial region
Percussion: 
Fluid thrill is present

 No hernial orifices
 No palpable mass
 tenderness is present 
 Liver is palpable 
 Spleen not palpable

CNS EXAMINATION:

  neck stiffness -no
 TREMORS ARE PRESENT 
 SPEECH IS NORMAL

 MOTOR REFLEXES

 Knee jerk reflex preset 
 Elbow reflex present
 Biceps reflex present
 Triceps reflex present
 Ankle reflex present

 SENSORY REFLEXES ARE INTACT
 CRANIAL NERVES ARE INTACT

PROVISIONAL DIAGNOSIS:

 Alcoholic liver disease

TREATMENT:

 patient  is on deaddiction and on alcohol  withdrawal treatment:




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