50 year old man with ascites

 

FINAL EXAMINATION LONG CASE REPORT 

NAME: K Pranati

Hall ticket no: 1701006093

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, resident of Pochampally, farmer by occupation came to Medicine OPD with complaints of : 

* Abdomen distension 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 jaundice and was treated at a private practitioner.


* Later he developed abdominal distension about 7 days ago - insidious in onset, gradually progressive to the present size - associated with 

  • Colicky pain in epigastric region and right hypochondrium .
  • High grade fever, not associated with chills and rigor, decreased on medication, No night sweats.
  • Not associated with Nausea, vomiting, loose stools 


* Pedal edema present. It was gradually progressive, Pitting type, Bilateral ,Below knees. It increases during the day - maximum at evening.

  • No local rise of temperature and tenderness 
  • Grade 2 
  • Not relived on rest 

*He also complained of shortness of breath since 4 days - MRC grade 4, Insidious in onset, Gradually progressive ,Aggravated 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. Ascites increased after his last drink on 29th May, 2022.


Daily Routine : 


*Wakes up at 5am and goes to field.

*Comes home at 8am and has rice for breakfast. Returns to work at 9am.

*Has lunch at 1pm

*Work 2-6 pm

*Returns to home at 6pm

*Dinner at 8pm

*Alcohol consumption twice 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 - insignificant 


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 ; 

                           - 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 nourished


*Icterus - present (sclera)

*Pedal edema - present - bilateral pitting type, grade 2                   


*No pallor, cyanosis, clubbing, lymphadenopathy.










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 


Liver, Spleen, Kidneys, Lymph nodes are not palpable 


PERCUSSION:

Liver span : not detectable 

Fluid thrill: felt 


AUSCULTATION: 

Bowel sounds: heard in the right iliac region 







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 

















PROVISIONAL DIAGNOSIS: 

Acute decompensated liver failure with ascites.


TREATMENT: 


1. Inj PAN 40 mg IV/OD

2. Inj LASIX 40mg IV/BD

3. Tab Spiranolactone 50mg/ BD

4. Inj Thiamine 1 amp in 100 ml NS IV/ TID

5. Syrup lactulose 15 ml/ TID

6. Abdominal girth charting 4th hourly

7. Fluid restriction <1L/ day

8. Salt restriction <2g/ day

Ascitic fluid was tapped twice- on 2nd June 2022 & 6th June 2022







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