A 50 years male came with Abdominal distension

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SHORT CASE

June 10, 2022

Name : Lakshmi Manvitha Yechuri  

Hall ticket no: 1701006096

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment plan.

CASE PRESENTATION : 

HISTORY :

A 50 year old male patient who is a farmer and a daily wage worker by occupation, a resident of Pochampally, came to the opd with

CHIEF COMPLAINTS :

1. Abdominal distension since 7 days

2. Pain abdomen since 5 days

3. Swelling of legs since 5 days

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic 6 months back, then he developed jaundice for which he was treated by a local private practitioner. 

15 days back he consumed more than the usual amount of alcohol following which he started experiencing some discomfort and since 7 days developed abdominal distension which was insidious in onset, gradually progressive and progressed to present size. There were no aggravating or relieving factors. 

Patient had pain abdomen which was insidious in onset, gradually progressive since 5 days in the epigastric and right hypochondriac region and had no aggravating or relieving factors.

Patient complained of swelling of legs which is grade 2 below the knee since 3 days which was insidious in onset, gradually progressive, pitting type, increased as the day progressed and had no relieving factors.

Associated symptoms : shortness of breath since 3 days.

No history of nausea and vomiting.

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.

There is no history of hospital admission.

PERSONAL HISTORY :

Diet : Mixed

Appetite : Decreased

Sleep : Adequate

Bowel and bladder movements : Urine frequency is reduced  and patient has an history of constipation.

Addictions : Patient is a chronic smoker and smoked 4-5 bidis per day since past 30 years 

Patient consumes alcohol occasionally (whenever he gets tired from work) - 90 ml of whiskey 

Patient consumes toddy occasionally 

FAMILY HISTORY :

No significant family history.

HISTORY OF ALLERGIES :

No known food or drug allergies.

GENERAL PHYSICAL EXAMINATION :

Patient is conscious, coherent, co-operative and well-oriented to time, place and person.

Patient is moderately built and is moderately nourished.

There is pedal edema of grade 2.

Icterus is present.

There is no pallor, cyanosis, clubbing, lymphadenopathy.

Vitals :

Temperature : Afebrile

Pulse rate : 90 bpm, regular, normal volume.

Respiratory rate : 22 cpm

Blood pressure : 130/90 mm Hg Right arm in sitting position 

GRBS : 90 mg/dl

O2 saturation : 98%

EXAMINATION OF HANDS AND ARMS :

Tremors  present. 

SYSTEMIC EXAMINATION :

Per abdomen :

On Inspection :

Abdomen appears to be distended and the umbilicus is everted.

Movements of Abdomen wall moves with respiration  

Skin is smooth and shiny.

No visible peristalsis, pulsations, sinuses, engorged veins 

Hernial sites.

On palpation :

There is no local rise of temperature.

Tenderness is present in the epigastrium.

No hepatomegaly. No splenomegaly.

Guarding is present.

Rigidity is absent.

Kidney not palpable.

On Percussion :

Tympanic note is heard on the midline of abdomen and a dull note is heard on the flanks in supine position. 

Shifting dullness : Positive 

Liver span could not detected 

Auscultation :

Bowel sounds are decreased.

Cardiovascular System : S1, S2 heard

Respiratory System : Normal vesicular breath sounds heard

Central Nervous System : Conscious; Speech normal ; Motor and sensory system examination is normal, Gait is normal.

INVESTIGATIONS :

1. Hemogram :

Hemoglobin : 9.8g/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

2. Serology : 

HbsAg : Negative

HIV : Negative

3. ESR :

15mm/1st hour

4. Prothrombin time : 16 sec

5. APTT : 32 sec

6. Serum electrolytes :

Sodium : 133 mEq/L

Potassium : 3 mEq/L

Chloride : 94 mEq/L

7. Blood Urea : 12 mg/dl

8. Serum Creatinine : 0.8 mg/dl

9. 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

10. 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

11. Ascitic Fluid Cytology :

12. Ascitic fluid culture and sensitivity report :

13. Ultrasound :

Coarse echotexture and irregular surface of liver - Chronic liver disease

Gross ascites

Gallbladder sludge

14. ECG

PROVISIONAL DIAGNOSIS :

Decompensated Chronic liver disease with ascites most likely etiology is alcohol. 

TREATMENT :

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

7. Fluid restriction less than 1L/day

8. Salt restriction less than 2g/day