1701006022 CASE PRESENTATION
LONG CASE
The patient was apparently asymptomatic 6 months ago then he developed jaundice and was treated at a private practitioner.
Later he developed abdominal distension about 4 days ago - insidious in onset, gradually progressive to the present size - associated with
- Pain in epigastric and right hypochondrium - colicky type.
- No H/o fever, No night sweats.
- Not associated with Nausea, vomiting, loose stools
- No history of hematemesis, dilated veins, hemorrhoids.
- No history of facial puffiness.
There was pedal edema
- Bilateral
- Pitting type
- 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
- Agrevated on eating and lying down ; No relieving factors
- 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
PAST HISTORY:
No history of similar complaints in the past
Patient is not a known case of Diabetes mellitus, Hypertension, Tuberculosis, Asthma, Epilepsy, Thyroid disease.
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, feeling of incomplete voiding.
- Allergies- none
-
Whiskey-180 ml, 2 times a week, since 5 years.
- Last alcohol intake - 29th May, 2022.
FAMILY HISTORY:
Not significant
GENERAL EXAMINATION:
Patient is conscious, coherent and co-operative.
Examined in a well lit room.
Moderately built and nourished
Pedal edema - present - bilateral pitting type (grade -2)
https://youtube.com/shorts/0tsxfSYduUA?feature=share
No pallor, icterus,cyanosis, clubbing, lymphoedenopathy.
Vitals :
Temperature- febrile
Respiratory rate - 16cpm
Pulse rate - 90 bpm
BP - 120/80 mm Hg.
SYSTEMIC EXAMINATION:
CVS : S1 S2 heard, no murmurs
Respiratory system : normal vesicular breath sounds heard.
Abdominal examination:
INSPECTION :
Abdomen is distended.
- Umblicus - everted
- Movements of abdominal wall - moves with respiration
- Skin is smooth and shiny;
- No scars, sinuses, distended veins, striae.
PALPATION :
No local rise of temperature.
Tenderness present - epigastrium.
Tense abdomen
Guarding present
Rigidity absent
Fluid thrill is positive
No hepatomegaly
No spleenomegaly
Kidneys not palpable
Lymph nodes not palpable
PERCUSSION:
Liver span : not detectable
Tympanic note is heard in midline of abdomen
Dull note heard on the flanks
Shifting dullness : Positive
Fluid thrill: felt
AUSCULTATION:
Bowel sounds: heard in the right iliac region
No bruits heard
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
Serology:
HIV - negative
HCV - negative
HBsAg - negative
Protein : 0.6 g/dl
Albumin : 0.34 g/dl
Sugar : 95 mg/dl
LDH : 29.3 IU/L
SAAG : 2.66 g/dl
-Coarse echotexture and irregular surface of liver - Chronic liver disease
-Gross ascites
-Gallbladder sludge
PROVISIONAL DIAGNOSIS:
Acute decompensated liver disease/Alcoholic liver with ascites.
TREATMENT:
-Abdominal girth charting - 4th hourly
-Fluid restrictriction less than 1L per day
-Salt restriction less than 2 gms per day
Drugs :
1. Inj. Pantoprazole 40 mg IV OD
2. Inj. Lasix 40 my IV BD
3. Inj. Thiamine 1 Amp in 100 ml IV TID
4. Tab. Spironolactone 50 mg BB
5. Syrup Lactulose 15 ml HS
6. Syrup Potchlor 10ml PO TID
CASE PRESENTATION:
The patient was apparently asymptomatic 6 months ago then he developed jaundice and was treated at a private practitioner.
Later he developed abdominal distension about 4 days ago - insidious in onset, gradually progressive to the present size - associated with
- Pain in epigastric and right hypochondrium - colicky type.
- No H/o fever, No night sweats.
- Not associated with Nausea, vomiting, loose stools
- No history of hematemesis, dilated veins, hemorrhoids.
- No history of facial puffiness.
There was pedal edema
- Bilateral
- Pitting type
- 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
- Agrevated on eating and lying down ; No relieving factors
- 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
PAST HISTORY:
No history of similar complaints in the past
Patient is not a known case of Diabetes mellitus, Hypertension, Tuberculosis, Asthma, Epilepsy, Thyroid disease.
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, feeling of incomplete voiding.
- Allergies- none
- Whiskey-180 ml, 2 times a week, since 5 years.
- Last alcohol intake - 29th May, 2022.
FAMILY HISTORY:
Not significant
GENERAL EXAMINATION:
Patient is conscious, coherent and co-operative.
Examined in a well lit room.
Moderately built and nourished
Pedal edema - present - bilateral pitting type (grade -2)
https://youtube.com/shorts/0tsxfSYduUA?feature=share
No pallor, icterus,cyanosis, clubbing, lymphoedenopathy.
Vitals :
Temperature- febrile
Respiratory rate - 16cpm
Pulse rate - 90 bpm
BP - 120/80 mm Hg.
SYSTEMIC EXAMINATION:
CVS : S1 S2 heard, no murmurs
Respiratory system : normal vesicular breath sounds heard.
Abdominal examination:
INSPECTION :
Abdomen is distended.
- Umblicus - everted
- Movements of abdominal wall - moves with respiration
- Skin is smooth and shiny;
- No scars, sinuses, distended veins, striae.
PALPATION :
No local rise of temperature.
Tenderness present - epigastrium.
Tense abdomen
Guarding present
Rigidity absent
Fluid thrill is positive
No hepatomegaly
No spleenomegaly
Kidneys not palpable
Lymph nodes not palpable
PERCUSSION:
Liver span : not detectable
Tympanic note is heard in midline of abdomen
Dull note heard on the flanks
Shifting dullness : Positive
Fluid thrill: felt
AUSCULTATION:
Bowel sounds: heard in the right iliac region
No bruits heard
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
Serology:
HIV - negative
HCV - negative
HBsAg - negative
Protein : 0.6 g/dl
Albumin : 0.34 g/dl
Sugar : 95 mg/dl
LDH : 29.3 IU/L
SAAG : 2.66 g/dl
-Coarse echotexture and irregular surface of liver - Chronic liver disease
-Gross ascites
-Gallbladder sludge
PROVISIONAL DIAGNOSIS:
Acute decompensated liver disease/Alcoholic liver with gross ascites.
TREATMENT:
-Abdominal girth charting - 4th hourly
-Fluid restrictriction less than 1L per day
-Salt restriction less than 2 gms per day
Drugs :
1. Inj. Pantoprazole 40 mg IV OD
2. Inj. Lasix 40 my IV BD
3. Inj. Thiamine 1 Amp in 100 ml IV TID
4. Tab. Spironolactone 50 mg BB
5. Syrup Lactulose 15 ml HS
6. Syrup Potchlor 10ml PO TID
Abdominal Distension since 1 year
Facial puffiness since 1 year
Itching all over the body since 1 year and developed multiple plaques on abdomen and Lower limbs
Sob since 5 days
pedal edema since 5 days pitting type
H/O PRESENT ILLNESS:
Patient was apparently asymptomatic 1 year back then she developed abdominal distension, facial puffiness,itching all over the body and 5 days ago she developed pedal edema and SOB grade 3.
PAST HISTORY:
she developed B/L Knee pain - since 3years, onset - insidious, gradually progressing, type- pricking, more at the night, aggravated on walking, relieved on sitting n sleeping, no radiation and is under medication( demisone 0.5 mg and acelogic SR)
Not a Known Case of DM/HTN/ asthma / Ischemic heart disease / epilepsy / TB
FAMILY HISTORY:
NO SIGNIFICANT FAMILY HISTORY
PERSONAL HISTORY:
OCCUPATION Daily wage worker
DIET MIXED
APPETITE decreased
SLEEP NORMAL
BOWEL AND BLADDER HABITS : decreased urine output
ADDICTIONS: None
GENERAL EXAMINATION
BP 110/80
PR 90bpm
TEMP 98.5degrees F
SPO2 98 @ RA
GRBS 106
NO PALLOR, ICTERUS , CYANOSIS, CLUBBING , LYMPHADENOPATHY ,
SYSTEMIC EXAMINATION:
P/A-
RS - BAE + , normal vesicular breath sounds
