1701006066 CASE PRESENTATION
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
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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
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A 46 year old male came with chief complaints of:
Burning micturition present since 10 days
Vomiting since 2 days ( 3 - 4 episode)
Giddiness and deviation of mouth since 1 day
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 10years back, he complained of polyuria for which he was diagnosed with Type 2 diabetes mellitus he was started on OHAs, 3years back OHAs were converted to insulin.
2 days back, he developed vomiting , containing food particles and non bilious. He also complained of deviation of mouth and giddiness 1 day
His GRBS was also recorded high , for which he was given NPH 10 IU and HAI 10 IU
OHAs were converted to insulin 3 years back
3 years back , he underwent cataract surgery
1 year back, he had h/o small injury on leg which gradually progressed to non healing ulcer extending upto below knee eventually ended with below knee amputation i/v/o development of wet gangrene
Not a k/c/o HTN/Epilepsy/TB/BA/Thyroid disorder/CAD/CVD
PERSONAL HISTORY:
Diet - Mixed
Appetite- normal
Sleep- Adequate
Bowel and bladder- Regular
Micturition- burning micturition present
Habits/Addiction:
Alcohol-
Not consuming alcohol since 1 yr.
Previously (1yr back) Regular consumption of alcohol, about 90mL whiskey consumed almost daily.Also 1 month on & off consumption pattern previously present
FAMILY HISTORY:
RS: BAE+,NVBS
P/A: Soft, Non tender
CNS:
Patient is having altered sensorium
Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)Normal
Power: Normal(5/5) in both Upper and Lower limbs
Tone: Normal in both Upper and Lower limbs
No meningeal signs
INVESTIGATIONS:
PROVISIONAL DIAGNOSIS:
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