50yr old man with ascites

FINAL EXAMINATION CASE REPORT

NAME: Meghana.M

Hall ticket no: 1701006118

Batch: 2017

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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)