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)

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 

Tremors: https://youtu.be/92FKSVP1onw

                 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: