20100006005 SHORT CASE 1
CASE : 3
A 50 year old Male came with chief complaints of abdominal distension since 4 days associated with shortness of breath since 3 days.
H/0 of yellowish discoloration of eyes 2 months back subsided, now started again since 4days
No h/0 of nausea and vomitings,
No h/0 of pain abdomen
No h/0 of decreased urine output
No h/0 of high coloured urine and clay coloured stools.
No history of blood transfusions
No bleeding manifestations.
No H/o usage of TB drugs or any other medication.
Pedal edema- Present (pitting type)
HEAD TO TOE examination:
Axillary hair loss seen
No parotid swelling
Palmar erythema absent
14.06.23 after paracentesis
Hyperpigmented patches seen on palm
Gynaecomastia present but non tender
Pale colour nails absent
Tremors absent
Spider naevi not seen
Petechiae, purpura not seen
GENERAL EXAMINATION
Patient is conscious, Oriented, Comfortable, Co-operative
afebrile
Pallor - present
Icterus - present
Cyanosis
– negative
Clubbing
– no
Pedal
edema – bilateral, painless, pitting
No Significant
lymphadenopathy
TROISIER’S SIGN - Negative
EXTERNAL MARKERS
OF LIVER CELL FAILURE -
HEAD AND NECK– No alopecia, no bitots spots, no xanthelasma , subconjunctival hemorrhage, pallor +, icterus+, no medial supraciliary madarosis, sunken eyes and cheeks, loss of facial hair, no parotid enlargement, bleeding gums
TRUNK – no spider nevi, no gynaecomastia, loss of pectoral/axillary hair present , no dilated veins, wasting, abdominal distension present , no caput medusae, no loss of pubic hair, no testicular atrophy, no scratch marks, purpura
UPPER LIMBS – left side dupuytrens
contracture present , no bounding pulse, no clubbing, no flapping tremor, no palmar
erythema, no pruritic marks
LOWER LIMBS – Pedal Edema present
NO BONY TENDERNESS,
GUM HYPERTROPHY, LEUKEMIA CUTIS
VITAL SIGNS
PULSE: 82 bpm regular rhythm,normal volume, felt in all peripheral pulses,no radioradial/radiofemoral
delay,no apex pulse deficit
BLOOD PRESSURE: 110/80 mm of Hg
measured in the left Upper limb with the patient in sitting position
RESPIRATORY RATE: 16/min,
regular abdominothoracic
TEMPERATURE: 98.2 F measured
in the Axilla
SYSTEMIC EXAMINATION
EXAMINATION OF THE ORAL CAVITY- normal
ABDOMEN:
INSPECTION:
1.
Shape
– distended
2.
Flanks
–full
3.
Umbilicus
–everted, no nodules
4.
Skin
– no stretched, shiny, scars, sinuses, striae, nodules, scratch marks, puncture
marks
5. No Dilated veins – front/back
6. Movements of the abdominal wall equal in all quadrants with respiration,
no visible gastric peristalsis,
7. Normal Hernial Orifices, no cough impulse
8. External genitalia - Normal
PALPATION:
Superficial
Palpation
– Tenderness, Warmth, Direction of Blood Flow in Veins
Deep
Palpation
1. Liver : non-tender,
non-pulsatile
Right hypochondrium about 1 cms below the Right costal margin in the Mid clavicular line
Which moves with respiration and is
firm in consistency with a irregular surface
And a rounded edge
And I am not able to make out the upper
border on Palpation
Probably an Enlarged liver
2.
Spleen
no significant spleenomegaly
Palpation
by Dipping in the case of Tense Ascites
Measurements - Abdominal Girth
Spino-Umbilical Distance
Distance between the Xiphisternum-Umbilicus and Umbilicus-Pubic Symphysis
External
Genitalia - normal
PERCUSSION:
1.
Shifting dullness - present
2.
Percussion
of Liver for Liver Span - Noat able to palpate
3. Tidal Percussion
AUSCULTATION:
1.
Bowel
sounds present – 10 to 15/min for small bowel, 3 to 5/min for large bowel
2. Bruit not heard
3. No Venous Hum
PER RECTAL EXAMINATION: stool stained
CARDIOVASCULAR
SYSTEM:
S1,
S2, no murmurs heard.
EXAMINATION OF
RESPIRATORY SYSTEM:
No Added
sounds
EXAMINATION OF
NERVOUS SYSTEM:
no Flapping
tremor, Peripheral Neuropathy
DIAGNOSIS
CHRONIC
DECOMPENSATED LIVER DISEASE, CIRRHOSIS WITH PORTAL HYPERTENSION WITHOUT
EVIDENCE OF HEPATIC ENCEPHALOPATHY
USG FINDINGS-
TREATMENT:
Fluid restriction
Salt restriction
1)TAB LASIX 40 mg/BD
2)TAB ALDACTONE 50 mg /BD
3)TAB UDILIV 300 mg po /BD
4)Syrup LACTULOSE 20 ml po /TID
