43 yr old male with complaints of abdominal distension and SOB since 15 days

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I have 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.

Case

Pt is a 43 yr old male with 
chief complaints of abdominal distension and sob since 15 days.
HOPI
Pt was apparently asymptomatic 15  days  ago then he developed  abdominal bloating ,no regurgitation , discomfort  is felt, aggravated after having food 
Shortness of breath noted after  having food ,on ordinary physical activity (grade 3 ) 
No h/o orthopnea ,chest pain, pnd , decreased urine output ,fever ,cough ,cold 
K/c/o htn and dm 2 since 3 yrs 
k/c/o alcoholic liver disease .

Personal history :  
His educational status is inter completed and didn't go for further studies as he is not interested . Then he depended on his family for financial support  upto 2013 ,then he joined finance based work did for 3 yrs then for raise in income he joined in wines shop management did for 4 yrs ,then he joined petrol bunk construction which  he is currently working in 
Daily routine.
His daily routine is waking up at 6am 
Going for a walk  7 am 
Getting ready and breakfast of idly/ dosa/ Vada and ready to work at 9 pm 
Comes to home by 1 pm for having lunch 
And went back to work 3pm and then he comes back at 8 pm for dinner and sleeps 9 pm.  And consumes alcohol in the breaks  for lunch and dinner and it causes late  in work timings .
His family is upset with his alcohol consumption and he isn't violent or abusive towards them .
He got married in 2004 
(Course of alcohol consumption) 

After 3 yrs in family function and festival occasion he is used to have toddy 750 ml noticeably frequent  in summer as seasonal commodity .
Then he started having beer 750 ml ,whisky 180 ml as per mood since 2010 due to influence of frnds and then continued due to pleasure .
As he was aware of consequences would have stopped intermittently for 1 month or so and then he would have started due to function and gathering and continued so ,due to his abdominal bloating ,uneasiness he used to stop .then due to chronic period of consumption he developed  withdrawal symptoms of uneasiness, fearfulness ,sweating etc .
He had h/o trauma    3   yrs ago bike vs auto and had left thigh fracture and treated for it in our hospital 
He got diagnosed with htn and diabetes during the period.
He then visited our hospital 3 months ago with complaints of vomiting later to find out alcoholic liver disease , he stopped consuming one month and then started on peer pressure and continued drinking
His last alcohol consumption is whisky 180 ml  on 16/6/23. Then came to our hospital on 20/6/23 for c/o abdominal distension and vomitings similar to past  visit to hospital.
General examination 
Icterus present
No :
Pallor 
Cyanosis
Clubbing 
Lymphadenopathy
Oedema 
Vitals
Temp:98.5°F 
Bp: 120/80 mmhg 
PR: 90 bpm
RR: 19 cpm

Systemic examination
Cvs : 

Precordium normal 
No thrills ,
On auscultation 
S1,S2 heard ,no murmurs 

CNS: 
Higher mental functions :intact
Cranial nerves :intact
Motor system:Normal power,tone,Gait
Reflexes:normal
Sensory examination:Normal
No meningeal signs
Tremors : absent

Rs: 
Shape of chest:Bilaterally symmetrical, Elliptical in shape
No visible chest deformities
No kyphoscoliosis,
Abdomino thoracic respiration, No irregular respiration

Trachea is central 
Auscultation: 
Normal vesicular breath sounds heard 

P/A
INSPECTION:

Shape of abdomen:Distended

Umbilicus:inverted

Skin over the abdomen is shiny

All quadrants are moving equally with respiration

No visible peristalsis, Hernial orifices intact

Visible superficial abdominal vein running vertically down is seen

External genitalia normal

PALPATION:

Temperature:Not raised
Tenderness:Absent
No Rebound tenderness 
No guarding rigidity
 Mild Hepatomegaly 

Percussion
No shifting dullness , 
No fluid thrill

Auscultation
Bowel sounds are heard.

Diagnosis

Alcoholic liver disease with alcoholic dependency syndrome 

Investigations  on  20/6/23
FBS - 173 mg/dl
Plbs - 258 mg /dl
ECG
  On 21/6/23
USG
2 d echo
On 22/6/23
On 23/6/23
Gastrology referral 
Endoscopy done 
Esophagyus :small hiatus hernia ,no varices ,grade D esophageal reflux disease 
Stomach : no blood seen ,diffuse gastritis 
Duodenum :d2 normal ,smooth globular extrinsic impression in d1 likely to be gb compression 
Advice 
Strict alcohol abstinence 
On 23/6/23
Psychiatry referral
Impression : alcoholic dependence syndrome. Currently abstinence 

Treatment
1.Tab .PAN 40 MG PO /OD
2.SYP.LACTULOSE PO/OD (9PM)
3TAB .GLIMI M1 PO OD 8AM
4.TAB . AMLODIPINE PO/OD 8 AM
5. TAB .LORAZEPAM 2 MG x 1 week
6.TAB .BACLOFEN XL 20 MG x. 1 week 
7.TAB .BENFOTHIAMINE 100 MG x 1 week
8. TAB.UDILIV 300 MG PO/BD 
9.TAB.BEFLEX FORTE PO/OD x 1 week
10.SYP .HEPAMERZ 15 ML PO/TID x 1 week 


Patient got discharged after explaining the alcoholic effects and medication mentioned above on 24/6/23.

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