50 Yr Old male with Abdominal distension and Sob (PREFINAL)
A 50 yr old male patient resident of thanamcherla farmer by occupation came with
Chief complaints:
Abdominal distension since 4 days
Shortness of breadth since 4 days
Pedal edema since 3 days
HOPI :
Patient was apparently asymptomatic 4 days back then he developed distension of abdomen which was insidious in onset ,gradually progressive had feeling of aggravation due to lifting weights and has no relieving factors
He also has shortness of breadth since 4 days (grade 2 ) acc to mmrc in which he felt Difficulty in breathing while walking to feilds about 2kms which he used to walk everyday which at present he is feeling difficulty while walking upto 1 km , relieved on taking rest for a while .
He also has complaints of pedal edema since 3 days which was insidious in onset gradually progressive , upto knees (grade 1) ,pitting type and had no relieving factors .
He also has yellowish discolouration of eyes.
He had a history of decreased urine output along with difficulty in passingly stools and was passing hard stools 4 days back which relieved on taking medication ?.
No h/o chest pain , palpitations, pnd,orthopnea, facial puffiness
No h/o fever , chills, rigor, myalgia, rashes
No h/o Hematemesis, maleana
No h/o abdominal pain, nausea, vomiting
No h/o altered sensorium, confusion,lack of intrest in work,hair loss, excessive sweating .
PAST HISTORY:
Sequence of events:
17.03.23
Visited a local clinic with complaints of yellowish discolouration of eyes and abdominal pain and was given medication ? and was not relieved.
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Then used herbal medicine? For 3 days on suggestion of neighbours but had not relieved any of his complaints
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25.03.23
He went to hospital in khammam and was diagnosed as Decompensated liver disease and was given medication .and was not relieved.
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19.04.23
Came with similar complaints of present ( abdominal distension,Sob and ascitic tap was done 300 ml was removed and endoscopy was also done and was diagnosed with oesophageal varices and given medication ( Tab. Udiliv300mg Od , Tab pan 40 mg OD , Syp. Lactulose 15 ML BD and was discharged.
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12.06.23
Now came with complaints of Abdominal distension and Sob along with pedal edema.
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14.06.23
Ascitic tap was done and 1000 ml of fluid was removed . As the patient was feeling difficulty in eating food with distended abdomen. Before ascitic tap abdominal girth was 88 cms and after ascitic tap it is 84 cms
Not a k/c/o Dm , Htn , Asthma, epilepsy, thyroid disorders, Cad.
No h/o any surgeries in past.
FAMILY HISTORY:
No relevant family history.
PERSONAL HISTORY:
He is a 50 yr old male resident of thanamcherla , farmer by occupation and was married 30 yrs back and has 2 daughters aged 27,25yrs and son aged 24 yrs.
DAILY ROUTINE:
He generally wakes up at 5 am then after getting freshen up he will go to field work at 6 am and works upto 9 am then have his breakfast and then again works for around 3 hrs upto 1 pm and then goes home and have his lunch and takes rest for 2 hrs and then again goes to field and works for another 2 hrs and then reaches home and eats his dinner at around 8 pm and then goes to sleep . Because of above complaints he has stopped his field work since 3 months .
Diet : Had mixed diet but stopped eating non veg due to suggestion of physician due to Liver disease
Appetite: Has a normal appetite
Sleep : adequate
Bowel and bladder movements: Regular
Addictions: Had a habit of taking alcohol since 20 yrs ( gudumba 180 ml per day ) and stopped using since 3 months on suggestion of doctor. Has no smoking habits.
Treatment history:
Before
Tab. Udiliv300mg Od
Tab pan 40 mg OD
Syp. Lactulose 15 ML BD
Now
GENERAL EXAMINATION:
Patient is conscious, coherent, cooperative and well oriented with time place person and moderately built and moderately nourished.
Pallor - Absent
Icterus- present
Cyanosis- Absent
Clubbing- Absent
Lymphadenopathy- Absent
Pedal edema- Present (pitting type)
HEAD TO TOE examination:
Axillary hair loss seen
No parotid swelling
Palmar erythema absent
Hyperpigmented patches seen on palm
Gynaecomastia present but non tender
Pale colour nails absent
Tremors absent
Spider naevi not seen
Petechiae, purpura not seen
Vitals:
Temp- Afebrile
Pulse - 75 bpm
Bp - 100/80
Rr- 18 cpm
SYSTEMIC EXAMINATION:
ABDOMINAL EXAMINATION:
INSPECTION:
Abdomen is distended with flank fullness
Umbilicus inverted
Skin over surface normal , No scars,engorged veins
No visible pulsations, peristalsis
No discolouration over skin
15.06.23
14.06.23 after paracentesis
PALPATION :
Abdomen is non tender , non rise in temperature
No organomegally.
Liver and spleen non palpable
PERCUSSION:
Upper border of liver dullness is felt at 6th ICS along mid clavicular line and lower border non felt due to distended abdomen.
No fluid thrill
Shifting dullness is present .
AUSCULTATION:
Bowel sounds are present
RESPIRATORY EXAMINATION:
INSPECTION:
Shape elliptical
Equal movements on both side
No scars sinuses engorged veins pulsations
Trachea appears central
PALPATION:
Trachea central
B/L sym chest expansion
Vocal fremitus is decreased in left mammary and inframammary
Left infrascapular regions
PERCUSSION:
Dullness noted in left inframammary , mammary, infrascapular regions
AUSCULTATION:
Absent breath sounds in inframammary and infrascapular areas
CVS EXAMINATION:
INSPECTION :
Shape of chest symmetrical
No engorged veins , no scars, no visible pulsations
JVP not elevated
PALPATION:
Apex beat felt at 5 ics
No thrills and Heaves felt
AUSCULTATION:
S1 s2 heard no murmurs
CNS EXAMINATION:
Conscious coherent cooperative
Higher mental function - intact
Cranial nerves intact
Sensory - normal
Motor-
Tone normal
Power B/L 5/5
Reflexes: Right , left
Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Knee ++ ++
PROVISIONAL DIAGNOSIS: Decompensated Chronic liver disease sec to chronic alcohol consumption.
INVESTIGATIONS:
Usg
X ray
Blood sugar
Ecg
DIAGNOSIS:
Chronic liver disease with features ( oesophageal varices, Ascites,splenomegally) suggestive of portal hypertension.
His Child pugh score is 9 and graded as Grade B with One year Survival rate at 80 and two year survival rate at 60
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