A 50 YEAR OLD MALE WITH ABDOMINAL DISTENSTION SINCE 3 DAYS

 13 JUNE 2023

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CHIEF COMPLAINTS

Pedal edema since 1 day

Abdominal distension since 3 days

Shortness of breath since 3 days

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 3 days back , then he developed abdominal distension  which was insidious in onset , gradually progressive in nature. He complained of shortness of breath since 3 days (grade 2) upon doing ordinary activity like walking to his field after eating.He used to walk 2km without any inconvenience but since 3 days he is able to walk upto 1km only. He also complained of pedal edema since 1 day which was insidious in onset, gradually progressive and confined upto ankles( grade 1) and pitting type.

H/O decrease in urine output since 3 days and difficulty in passing stools and passing hard stools since 3 days which relieved on taking medication.

No H/O blood in urine, burning micturition, increased frequency and urgency.

No H/O orthopnea, paroxysmal nocturnal dyspnoea, hematemesis.

No H/O abdominal pain, nausea ,vomiting, darkly stained stools and diarrhoea.

No H/O chest pain, palpitations, facial puffiness

No H/ O yellowish discoloration of eyes,tremors, altered sensorium, confusion, lack of interest in work, hair loss ,sweating after stopping the alcohol.

No H/O fever, chills, rigor, myalgia, joint pain and  rashes.

PAST HISTORY

 H/O similar complaints 3 months back and diagnosed as decompensated liver disease for which he was treated here and he continued taking medication since discharge and stopped taking them since two days before developing the recent symptoms.

Endoscopy was done here 3 months back and oesophageal varices were detected.

No H/O hypertension, diabetes mellitus, tuberculosis, asthma, coronary artery disease, epilepsy.

No H/O any surgeries.

FAMILY HISTORY

No similar complaints in the family.

PERSONAL HISTORY 

Patient is a 50 year old male hailing from thanamcherla, who is farmer by occupation, married(  consanguineous) at 20 years and has three children.

Daily routine : He wakes up at 5'O clock and goes to his farm by walk, comes back after an hour, eats breakfast and lunch which are rice and vegetable curries.He takes afternoon nap for one hour, then again goes to his farm for sometime and comes back for dinner and then sleeps.

Diet : vegetarian, stopped eating non vegetarian foods 3 months back.

Appetite : normal

Sleep : adequate

Bowel movements: decreased

Bladder movements: decreased 

Addictions :  he had been drinking gudumba since 30 years but stopped from past 3 months on doctor's advice. He used drink gudumba 90ml twice a day.

GENERAL EXAMINATION:

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

Patient is moderately nourished and moderately built 

Height -5’5

Weight -60kgs

Pallor -absent 

Icterus -present 

Cyanosis- absent

Clubbing - absent

Lymphadenopathy - absent

Pedal edema - present (grade 1)

No parotid swelling 

Palmar erythema- absent 

Gynaecomastia -absent 

Pale coloured nails -absent

Tremors-absent

Absent spider naevi 

Petechae -absent 

VITALS 

Afebrile 

Blood pressure-110/70mm Hg

Pulse-78bpm

RR-18cpm,abdominothoracic

SYSTEMIC EXAMINATION 

ABDOMINAL EXAMINATION:

INSPECTION-

Abdomen is distended and there is flank fullness

Umbilicus is inverted

Skin is normal without any scars

No discolouration of skin ,engorged veins,sinuses 

No visible peristalsis or pulsations 

Hernial orifices Normal 

PALPATION-

Abdomen is non tender and no local rise in temperature 

No guarding and rigidity 

No organomegaly 

PERCUSSION-

liver :Upper border of liver dullness is percussed at the right 6th ics along mid clavicular line and lower border cannot be palpated

Spleen:cannot be palpated

No fluid thrill  

shifting dullness present

AUSCULTATION-

Bowel sounds heard

CNS EXAMINATION:

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes: Right. Left. 

Biceps. ++. ++

Triceps. ++. ++

Supinator ++. ++

Knee. ++. ++

Ankle ++. ++

CARDIOVASCULAR SYSTEM EXAMINATION:

Inspection : 

Shape of chest- elliptical 

No engorged veins, scars, visible pulsations

JVP - not raised

Palpation :

 Apex beat can be palpable in 5th inter costal space

No thrills and parasternal heaves can be felt

Auscultation : 

S1,S2 are heard

no murmurs.

RESPIRATORY SYSTEM EXAMINATION:

Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

No scars, sinuses, engorged veins, pulsations 

Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: resonant bilaterally 

Auscultation:

bilateral air entry present. Normal vesicular breath sounds heard.

PROVISIONAL DIAGNOSIS 

 Decompensated chronic liver disease 2° to chronic alcohol consumption.

INVESTIGATIONS

USG ABDOMEN:

 

Gross ascites

Mild splenomegaly

Irregular echo texture of liver

Left renal cortical cyst.

HEMOGRAM:

LIVER FUNCTION TESTS:

RENAL FUNCTION TESTS:

CHEST X-RAY:

APTT:

PROTHROMBIN TIME:

TREATMENT:

 

Tab ALDACTONE 50 mg PO/OD

Tab PAN 40mg PO/OD

Syrup LACTULOSE 30ml PO/HS in 1 glass of water

Syrup POTKLOR 15ml in 1glass water PO/BD

Injection Vitamin K 10mg IV/OD

BP, RR, PR monitoring 2 hourly.

FINAL DIAGNOSIS:

Chronic liver disease with features of portal hypertension i.e, ascites,splenomegaly and oesophageal varices.