50yr old man with ascites


FINAL EXAMINATION CASE REPORT 

NAME: Meghana.M

Hall ticket no: 1701006118

Batch: 2017



 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box"


50 year old male, farmer by occupation, resident of Pochampally, came to Medicine OPD with complaints of : 

* Distended abdomen since 7 days 
* Pain abdomen since 7 days
* Pedal edema since 5 days 
* Breathlessness since 4 days.




HISTORY OF PRESENT ILLNESS: 

The patient was apparently asymptomatic 6 months ago when he developed fever with jaundice and was treated at a private practitioner.


Later he developed Abdominal distension about 7 days ago after consuming unusual amounts of alcohol at a gathering,

 - insidious in onset, gradually progressive to the present size - associated with 

  • Pain in epigastric and right hypocondrium - 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,

  • Pitting type
  • Bilateral 
  • Started at the ankle gradually progressed to below knees
  • Increases untill the end of the day - maximum at evening.
  • No local rise of temperature and tenderness 
  • Grade 2 
  • Not relieved on rest 

He also complained of Shortness of breathe since 4 days - MRC grade 4

  • Insidious in onset
  • Gradually progressive 
  • Agrevated on eating and lying down ; No relieving factors
  • No PND
  • No cough/sputum/hemoptysis
  • No chest pain
  • No wheezing



Patient is a known alcoholic since 20 years.  Distention increased after his last drink five days back. 


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, feeling of incomplete voiding. 
  • Allergies- none
  • Addictions -
  •  Beedi - 8-10/day since 20 years, smoking index= 10×20= 200 ; 

          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.


FAMILY HISTORY:

Not significant 


GENERAL EXAMINATION: 

Patient is conscious, coherent and co-operative.

Examined in a well lit room.

Moderately built and moderately nourished


Icterus - present (sclera)



Pedal edema - present - bilateral pitting type, grade 2                   - https://youtube.com/shorts/Uwz_0gxzqUM?feature=share



No pallor, cyanosis, clubbing, lymphoedenopathy.







Vitals : 

Temperature- febrile

Respiratory rate - 16cpm

Pulse rate - 101 bpm

BP - 120/80 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 



https://youtube.com/shorts/dRnY4B6YVV8?feature=share


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 






                 https://youtu.be/_fa8fWJ7zQo




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


SEROLOGY:

HIV - negative 

HCV - negative 

HBsAg - negative 



ASCITIC TAP:

https://youtu.be/ym_1Y6y3ZpM



ASCITIC FLUID CYTOLOGY:


CULTURE AND SENSITIVITY:



ECG:


HEMOGRAM:




ACSITIC FLUID PROTEIN










ULTRASOUND ABDOMEN:
Coarse echotexture and irregular surface of liver - Chronic liver disease
Gross ascites
Gallbladder sludge




PROVISIONAL DIAGNOSIS: 

Decompensated chronic liver failure with ascites secondary to alcohol consumption.


TREATMENT


Inj. Pantoprazole 40 mg IV OD

Inj. Lasix 40 my IV BDI

Inj. Thiamine 1 Amp in 100 ml IV TID 

Tab. Spironolactone 50 mg BB

Syrup Potchlor 10ml PO TID

Syp. Lactulose 15ml TID


Abdominal girth charting - 4th hourly


Fluid restrictriction less than 1L per day


Salt restriction less than 2 gms per day




Ascitic fluid tap done twice:










Comments

Popular posts from this blog

52/F with pyrexia and body pains

MEDICINE CASE BASED LEARNING || Online assignment for the month of MAY 2021

55/M Pyrexia with ?Septic shock