52 YEAR OLD MALE WITH ABDOMINAL DISTENSION

Kausalya Varma, Intern 

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. 



52 YEAR OLD MALE WITH ABDOMINAL DISTENSION 


CHIEF COMPLAINTS:

A 52 year old male came with the chief complaints of fever and chills since yesterday night and distension of abdomen since today afternoon. He also has complaints of decreased urination since today afternoon.


HISTORY OF PRESENTING ILLNESS:

- Patient was apparently asymptomatic 1 day ago, after which he developed fever which was low grade, 1 episode, associated with chills, subsided on medication. 

- He has complaints of distension of abdomen since today afternoon which was insidious in onset, gradually progressing, associated with mild lower abdominal discomfort and has no aggravating or relieving factors. Patient has been passing flatus. Patient passed stools- 2 episodes since 6pm today. 

- He also had complaints of decreased urination since today afternoon.

- H/O sudden weakness of all four limbs (lower limbs>upper limbs) since the afternoon. 

- H/O trauma to the neck (after a fall post alcohol intake) 2 years back. He suffered a traumatic spinal cord injury with a C5-C6 laminectomy and lateral mass fixation.

- Patient received physiotherapy. He has had a regular change of foleys catheter every 15 days since 2020


PAST  HISTORY:


- H/O similar complaints of mild abdominal distension- 2 episodes in 2020

- H/O use of Tab Baclofen 10mg daily since 2020

- Not a K/C/O DM, HTN, asthma, epilepsy or CKD 



PERSONAL HISTORY:

Diet- Non vegetarian 
Appetite- Decreased 
Sleep- Adequate 
Bowel and Bladder movements-  He has constipation for the past 2 years 
A foleys catheter has been placed for him for the past 2 years, which is changed every 15-20 days 
Addictions- Takes alcohol occasionally 

Family history- not significant 

GENERAL EXAMINATION:


The patient was conscious, coherant, and co-operative and well oriented to time, place and person. With prior consent, patient was examined in a well lit room, lying down on the bed. She in well built and well nourished.


Pallor- Present

Icterus- Absent 

Clubbing- Absent

Cyanosis- Absent

Lymphedenopathy- Absent

Edema- Absent

Koilonychia- Absent








VITALS

(At admission)

Temperature- 100.5

Pulse rate- 96 bpm

Blood pressure- 90/60 mmHg

Respiratory rate- 34 cpm

GRBS- 145mg/dl 

Sp02 at room temp- 90%


SYSTEMIC EXAMINATION:


SYSTEMIC EXAMINATION: 

RESPIRATORY SYSTEM-  


Inspection-

Chest is bilaterally symmetrical

The trachea is positioned centrally

Apical impulse is not appreciated 

Chest moves normally with respiration

No dilated veins, scars or sinuses are seen


Palpation

Trachea is felt in the midline 

Chest moves equally on both sides 

Apical impulse is felt in the fifth intercostal space 

Tactile vocal fremitus- appreciated 


Percussion-

The areas percussed include the supraclavicular, infraclavicular, mammary, axillary, infraaxillary, suprascapular, infrascapular areas.

They are all resonant.


Auscultation-

Normal in all areas 



CARDIOVASCULAR SYSTEM- 


Inspection

The chest wall is bilaterally symmetrical

No dilated veins, scars or sinuses are seen

Apical impulse or pulsations cannot be appreciated 


Palpation-

Apical impulse is felt in the fifth intercostal space, 2 cm away from the midclavicular line

No parasternal heave or thrills are felt 


Percussion

Right and left borders of the heart are percussed 


Auscultation-

S1 and S2 heard, no added thrills and murmurs are heard 


ABDOMEN EXAMINATION

INSPECTION:

Shape – distended 
Flanks – free
Umbilicus –central in position , inverted.
All quadrants of abdomen are moving equally with respiration.
No dilated veins, hernial orifices, sinuses
No visible pulsations.

PALPATION:
Soft, non tender, no fluid thrill, no shifting dullness, no guarding, no rigidity, no palpable lumps 
No local rise of temperature and tenderness
All inspectory findings are confirmed.
No guarding, rigidity
Deep palpation- no organomegaly.
Hernial orifices normal 

PERCUSSION:

Percussion over abdomen- tympanic note heard.

AUSCULTATION:
Bowel sounds are heard.


CENTRAL NERVOUS SYSTEM-


Pupils- left- dilated non reactive to light

               right-NSRL

Higher mental functions

- Conscious

- Oriented to  time,place and person

- Memory - Intact

- Speech - no deficit


Cranial nerve examination 


          • 1 - olfactory sense - normal


          • 2- visual acuity present,direct reflex R    L

                                          +   -.                    

            Indirect reflex +   -

          • 3,4,6 - no ptosis Or nystagmus


          • 5- corneal reflex present 


           • 7- no deviation of mouth, no loss of nasolabial folds, forehead wrinkling present


          • 8- Decreased hearing


          • 9,10- position of uvula is central ,Gag reflex- present


          • 11- sternocleidomastoid contraction present


          • 12- no deviation of tongue


 Motor system 


Reflexes 

                          Right        Left            

Biceps                3+            2+      

Triceps                3+            2+       

Supinator            2+            2+

 Knee.                  2+.           2+

Ankle.                   1+.           1+

Plantars- extensor     extensor

Power.           Lt.        Rt

Upper limb -5/5.       5/5


Lower limb  -3/5       3/5                                  

               


TONE.                    Lt.        Rt

 Upper limbs           N        N                

 Lower limbs           N    increased                 


No Involuntary movements

 SENSORY SYSTEM


I – SPINOTHALAMIC       R     L

1. Crude touch                 N     N 

2. Pain.                              N.    N

3. Temperature.               N.     N

II – POSTERIOR COLUMN

1. Fine touch.                    N.    N

2. Vibration.                      N.     N

3. Position sense.             N.     N

4. Romberg’s sign  -Negitive

III – CORTICAL

1. Two point 

    discrimination.               N.    N

2. Tactile localisation.       N.    N

3. Graphaesthesia.            N.    N

4. Stereognosis.                N.    N

 CEREBELLAR Tests

No Nystagmus

Finger Nose test - normal

Heel Knee test - normal

Dysdiadokokinesia - normal 


INVESTIGATIONS 

HEMOGRAM

Hemoglobin: 14.6
TLC: 9,700
Platelet: 1.50
PCV: 45.0

ELECTROLYTES
Na: 136
Cl: 102
K: 3.5


RENAL FUNCTION TESTS
Urea: 39
Creatinine: 1.1

LIVER FUNCTION TESTS
Total Bilirubin: 3.04
Direct Bilirubin: 1.02
SGPT: 78
SGOT: 166
ALP: 144
Total Protein: 4.9
Albumin: 2.77
A/G: 1.30

FEVER CHART- 


ULTRASOUND- 



X-RAY- ABDOMEN 



PROVISIONAL DIAGNOSIS-


Paralytic ileus secondary to hypokalemia 

True Hyponatremia (Hypotonic Hyponatremia)

S/P C5-C6 laminectomy 2 years back 



TREATMENT- 


IV fluids NS,RL @75ml/hr

Inj taxim 1g IV BD

Inj Optineuron 1amp IV in 100ml NS IV OD 

Tab PAN 40mg PO OD 

Tab DOLO 650mg PO SOS 

Proctosedyl ointment for L/A 

Syp Cremaffin 15ml PO OD 

Strict vital monitoring 4th hourly and inform SOS 




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