A 60 Y Male chronic alcoholic presented to the OPD with distended abdomen

12th July 2023

NOTE: THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.

This is the case of a 60 year old male farmer and carpenter by occupation and resident of Guramguda. The following history was taken with the patient in person. The patient was explained about confidentiality and written consent was taken to create the following case report.

This case report aims to record the patient's journey.

CHIEF COMPLAINTS:- 

-Abdominal distension since 4months

-Swelling of bilateral lower limbs since 4 months

-decreased urine output since 4months.

History of present illness:- 

Patient was apparently asymptomatic 4months back. He then developed abdominal distension which is insidious in onset and associated with pain which is stabbing type ,aggravated on eating and no relieving factors.

-H/O swelling in both legs upto level of knees associated with dragging type of pain since 4months.

-H/O decreased urine output since 4months.

-H/O SOB since 4months

-Patient then went to a hospital and on medication complaints were subsided. He developed the same complaints 10days back and came to the our OPD hospital yesterday(i.e 7th july 2023).

-H/O chronic cough since 4months with whitish sputum.

-H/O burning micturition since 1month.

-H/O intermittent fever since 10 days associated with chills and rigors relieved on medication.

-Other complaints- presence of  spherical swelling insidious in onset (1month ago) infront of leg 9inches from the lower border of patella initially in the size of a peanut and progressive to the current size measuring 3x3cm. The swelling is tender, firm in consistency and no mobility and punctum is seen.

No H/O nausea, vomitings , chest pain , palpitations, giddiness , sweating and jaundice. 

History of past illness:-

H/O 2episodes of seizures 12years ago controlled by medication.

H/O spasms of both limbs phalanges

K/C/O Type 2 DM and HTN since 6years.

N/K/C/O- TB, asthma, CVA , CAD , Thyroid disorders.

Surgical history

Cataract removal for one eye 2years ago and other eye 1year ago.

Removal of cyst like swelling present between two eyebrows 1year ago.

H/O blood transfusion done 3months back-uneventful

Personal history:-

Water intake:- half a litre per day

Appetite:- decreased appetite since two months

Diet:- mixed 

Bowel movement:- H/O constipation since 1 month, passing stools once in 3days.

Bladder movement:- decreased urine output since 4months with burning micturition since 1month.

Alcohol:- Chronic alcoholic since 40years(around 180ml/day)

Smoking:- chronic smoker since 40years(one pack of beedi per day containing 18 beedis)

Addiction:- nil

Allergies:- nil

Exercise status:- moderate

FAMILY HISTORY:-

- not significant. 

PHYSICAL EXAMINATION:-

GENERAL EXAMINATION:-

The examination was conducted at a well lit and well ventilated room. The patient was conscious, cooperative and coherent. 

Moderately built

Afebrile

Pallor present

No Icterus

No Cyanosis

No Clubbing.

Bipedal edema -present pitting type 

No Significant lymphadenopathy

VITALS:

Temp- Afebrile

BP-140/70

PR-105bpm

RR-24cpm

Spo2-96% at room air

GRBS:485mg/dl

SYSTEMIC EXAMINATION:

CVS:

Inspection -

Chest wall is bilaterally symmetrical 

Ne precordial bulge is seen

Palpation-

JVP- Normal

Apex beat-palpated in 5th intercostal space in mid clavicular line

Auscultation-

S1&S2 are heard

No murmurs

RESPIRATORY SYSTEM:

Position of trachea- central

Bilateral air entry, normal vesicular breath sounds are heard.

No added sounds

CNS:

Higher mental functions are present.

Patient is conscious ,coherent and co operative , well oriented to time and space.

Speech normal.

Motor and sensory system- Normal

Reflexes - present

Cranial nerves - intact

PER ABDOMEN:

Inspection:

Abdominal distension-present

Abdominal girth 85cms

All quadrants are moving equally with respiration

Umbilicus - central and inverted

Engorged Veins present

No scars, prominent Venous pulsations and visible peristalsis.

On palpation:

Superficial palpation- No Local rise in temperature and no tenderness.

Deep palpation- No guarding, rigidity.

On percussion:

Tympanic note - heard 

Shifting Dullness present

On auscultation:

Bowel sounds heard 

Provisional Diagnosis- 

Chronic liver disease with Portal Hypertension and Anemia.

Investigations:

RBS

PLBS:

Sr IRON:

Lipid profile:

Hemogram:

Blood Grouping:

Reticulocyte count:

APTT:

PT-INR:

Serology:

 

Ascitic Fluid for LDH:

SAAG:

RFT:

UKB:

CUE:

ECG:

2D Echo:

Chest Xray:PA view

USG Abdomen:

Treatment-

1.Inj.HAI 6units IV/STAT

2.Inj.HAI SC/TID

3.Tab.LASIX 40mg PO/BD

4.Tab.PCM 650mg PO/OD

5.GRBS monitoring.

6.Tab.pan 40mg PO/OD

7.syrup cremaffin plus 

8.2 egg whites per day

9.Tab.udiliv 300mg PO/BD

10.Inj.vitamin k

11.Tab.rifagut 550mg PO/OD

12.syrup.Hepamerz 10ml PO/BD