50 year old male patient with abdominal distension

FINAL EXAMINATION CASE REPORT 

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LONG CASE : FINAL PRACTICAL

Name : Jatin Sharma

Hall ticket no : 1701006066

HISTORY:

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 hypochondrium - 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

- Aggregated on eating and lying down ; No relieving factor

- 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, no 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 , amount : more then usual.

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

No pallor, cyanosis, clubbing, lymphadenopathy.

 

Vitals : 

Temperature- afebrile

Respiratory rate - 16 cpm

Pulse rate - 98 bpm

BP - 130/90 mm Hg.

SYSTEMIC EXAMINATION: 

CVS : S1 S2 heard, no murmurs

Respiratory system : normal vesicular breath sounds heard.

Abdominal examination: 

INSPECTION : 

Shape of abdomen- distended

Umblicus - everted

Movements of abdominal wall - moves with respiration 

Skin is smooth and shiny;

No scars, sinuses, distended veins, striae.

PALPATION : 

Local rise of temperature present.

Tenderness present - epigastrium.

Tense abdomen 

Guarding present

Rigidity absent 

Fluid thrill positive 

Liver not palpable 

Spleen not palpable 

Kidneys not palpable 

Lymph nodes not palpable 

PERCUSSION: 

Liver span : not detectable 

Fluid thrill: felt 

AUSCULTATION: 

Bowel sounds: heard in the right iliac region 

CNS EXAMINATION: 

Conscious 

Speech normal

No signs of meningeal irritation 

Cranial nerves: normal

Sensory system: normal

Motor system: normal

Reflexes:      Right.           Left. 

Biceps.         ++.                 ++

Triceps.         ++.                 ++

Supinator      ++.                  ++

Knee.              ++.                 ++

Ankle              ++.                  ++

Gait: normal 

INVESTIGATIONS: 

 

- Hemogram :

Hemoglobin : 9.8 g/dl

TLC : 7,200

Neutrophils : 49%

Lymphocytes : 40%

Eosinophils : 1% 

Basophils : 0%

PCV : 27.4%

MCV : 92.3 fl

MCH : 33 pg

MCHC : 35.8%

RDW-CV : 17.6%

RDW-SD : 57.8 fl

RBC count : 2.97 millions/mm3

Platelet count : 1.5 lakhs/mm3

Smear : Normocytic normochromic anemia

- LFTs :

Total Bilirubin : 2.22 mg/dl

Direct Bilirubin : 1.13 mg/dl

AST : 147 IU/L

ALT : 48 IU/L

ALP : 204 IU/L

Total proteins : 6.3 g/dl

Serum albumin : 3 g/dl

A/G ratio : 0.9

- ESR :

15mm/1st hour

- Prothrombin time : 16 sec

- APTT : 32 sec

- Serum electrolytes :

Sodium : 133 mEq/L

Potassium : 3 mEq/L

Chloride : 94 mEq/L

- Blood Urea : 12 mg/dl

- Serum Creatinine : 0.8 mg/dl

- Ascitic fluid :

Protein : 0.6 g/dl

Albumin : 0.34 g/dl

Sugar : 95 mg/dl

LDH : 29.3 IU/L

SAAG : 2.66 g/dl

- Serology : 

HbsAg : Negative

HCV : Negative

HIV : Negative

chest xRay

 

ECG

 

USG Abdomen

Ascitic fluid cytology

Culture And Sensitivity Report

 

PROVISIONAL DIAGNOSIS: 

Acute decompensated liver failure with ascites.

TREATMENT: 

Fluid restriction less than 1L per day     

Salt restriction less than 2 gm per day   

Inj. Pantoprazole 40 mg IV OD

Inj. Lasix 40 my IV BD

Tab. Spironolactone 50 mg BB

Inj. Thiamine 1 Amp in 100 ml IV TID

Syrup Potchlor 10ml PO TID

Syp. Lactose 15ml TID 

Ascitic fluid tapping