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.

 DAILY ROUTINE AND BIOPSYCHO SOCIAL HISTORY:

- He is a 50 year old gentlemen who stays with his mother, his wife and his son.

he had two elder daughters who got married at age of 18 years (elder daughter) and second daughter got married at age of 20 years.

- Before their marriage he used to work for annual income of around 8000-10000 at a farmer house who has many acres of land which are used for farming. 

- Later after their marriage he stopped working at that farmer and started to farm his own 1 acre and also used to work in muncipal office where he used to wake up at early morning 5 am and used to clean roads ,schools , other government offices and comes to home by 9-10am and with friends of muncipal offfice he used to go near alcohol vending shop and used to buy 1 litre of sara(local alchol drink) which costs him around 150-200 rupees.

- this used to be his routine lifestyle for the last 10-12 years .

PRESENT ILLNESS:

- One fine day ,Around February 2023, an ASHA worker had visited the patient in his area for a routine check up and had noticed and mentioned to the patient about the yellowish discolouration of his eyes 

- for which he got it checked at a local nearby hospital and was given conservative management for the same for which the symptoms were relieved . since then patient had stopped consuming these alcohol related drinks.

- Sometime in April 2023, patient then he developed distension of abdomen that was insidious in onset, gradually progressing associated with shortness of breath (grade 2 of MMRC)

-for which he was admitted into our hospital where he got treated conservatively along with a therapeutic ascitic tap that was done. 

- Ever since then, he has stopped consuming alcohol and moved to a more vegetarian diet.

Presently, patient who is on regular medication who came with 

- abdominal distension- insidious in onset, gradually progressive associated with Shortness of breath- of grade II type i.e, walks slower than usual and usually stops to catch his breath (MMRC). 

- no h/o fever, cold, cough, chest pain, orthopnoea, PND 

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.

PAST HISTORY- 

-No history of Hypertension, Diabetes Mellitus, CVA, Tuberculosis, Asthma.

- no past surgical history. 

- no h/o allergies.

- During us admission 3 months back, an endoscopy was done i/v/o Oesophageal varices grade 3-4

https://youtu.be/0Q9LmL09i2s

PERSONAL HISTORY- 

DIET- Presently a more vegetarian based diet

APPETITE- Normal 

BOWEL AND BLADDER MOVEMENT- regular 

SLEEP- adequate

HABITS- Stopped alcohol consumption 4 months ago. Otherwise was a chronic alcoholic for 20 years, namely consuming Sara, a country alcohol having about 25 to 45 % alcohol content with 100-120gm/day

FAMILY HISTORY- Insignificant 

PROVIOSIONAL DIAGNOSIS:

Decompensated chronic liver disease secondary to ethanol consumption, with ascites, portal hypertension with no hepatic encephalopathy.

GENERAL PHYSICAL EXAMINATION- 

- Well built and moderately nourished

- Weight : 60kgs

- Height : 164 cm

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

 

 EXAMINATION OF OTHER SYSTEMS

 

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

INVESTIGATIONS DONE : 

On 13/06/2023-

Chest X-ray PA view 

USG FINDINGS- 

- Irregular and coarse echo texture of Liver

- Mild splenomegaly

- Gross Ascites (s/o chronic liver disease) 

14/06/2023

Diagnostic Ascitic tap done of around 1000ml - 

15/06/2023- 

16/06/23-

Ascitic tap was done of around 500ml 

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