Short Case Discussion

 04/06/2022

Samhita Ghanathay

Hall ticket number - 1701006161

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50 year old male with abdominal distension 

I've been given this case to solve, in an attempt to understand the topic of "patient clinical data analysis" to develope my competency  in reading and comprehending clinical data - including history, clinical findings, investigations - and come up with diagnosis and treatment plan.

Following is a brief about the case.

CHIEF COMPLAINTS:

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 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 

• 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 

• Gradually progressive 
• Pitting type
• Bilateral 
• Below knees
• 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 
• 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. 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.

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 ; 

                           - 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

(These were taken on 2nd day post admission, so findings are not that prominent).

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 

Tremors seen.

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 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 

* ECG: Normal.

*Hemogram:

* Ascitic tap - done 2 times.

*Ascitic Fluid cytology - 

Cytosmear study - 

- few scattered Lymphocytes 

- reactive mesothelial cells against granular eosinophilic proteinaceous background

- no atypical cells

Impression - negative for malignancy.

* Culture and sensitivity report-

- AFB - negative

- Gram stain- few Epithelial cells. No inflammatory cells

- No organisms seen.

*Ascitic Fluid reports:

*Ultrasound abdomen:

Coarse echotexture and irregular surface of liver  Chronic liver disease

Gross ascites

Gallbladder sludge

PROVISIONAL DIAGNOSIS: 

Acute decompensated liver failure with ascites- secondary to alcohol consumption.

TREATMENT: 

Inj. PAN 40mg IV OD

Inj. Lasix 40mg IV BD

Inj. Thiamine 1 amp in NS 100ml IV TID

tab. Spironolactone 50mg PO BD

Syp. Lactose 15ml PO HS

Abdominal girth charting - 4th hourly

Fluid restrictriction less than 1l per day

Salt restriction less than 2 gms per day