50year old male with abdominal distension,SOB,pedal edema

A50 year old male farmer by occupation came with 

CHIEF COMPLAINTS:

ABDOMINAL DISTENSION Since5 Days

SHORTNESS OF BREATH Since 5 Days

B/L PEDAL EDEMA Since 5 days

HOPI:

Patient was apparently asymptomatic 5 days ago.

An asha worker during kallavelugu programme noticed and advised him to go to hospital for yellowish discoloration of eyes 5months ago.So he went to local clinic and advised to use unknown medications for 5 days ,which he used it  for 3 days but it was not reduced.

Then he went to hospital at khammam and the unknown investigations were done along with endoscopy, medications were given which he used for 5 to 6 days

He used herbal medicine (aaku pasaru) for 3 days/ once a week/for 3 weeks

Later he came here with complaints of yellowish discoloration of eyes and mild abdominal distension investigations were done 4 months ago n medications given which he used for 3 months

All of a sudden the patient developed abdominal pain which was sudden in onset, gradually progressive associated with fever for that he went to khammam hospital n medications were used 

He met a known doctor in a family function,showed all reports n he advised him to stop medications which were given at khammam hospital.Given him some extra unknown medications ,On that the abdominal distension got reduced as he used it for 3 days

During there thanda related festival he went out to bring some sticks for cooking purpose,there he found out that he's feeling shortness of breath and abdominal distension getting increase .So he stopped goin to feild work from then.He didnt go to any hospital but used the medications given here

 On tuesday (13/6/2023) he came here with the complaints of abdominal distension which was insidious in onset ,gradually progressive which was aggravating on exertion (lifting weights) and no relieving factors

 He also has shortness of breadth which is of grade -2( mmrc) since 5 days as 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 has pitting type(grade -1) of  pedal edema bilaterally upto knees since 5 days which was insidious in onset gradually progressive and no relieving factors .

He also has yellowish discolouration of eyes.

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:

Not a known case of DM,HTN,Asthma, Epilepsy,CVA,TB

No h/o surgeries in the past

No h/o blood transfusions 

FAMILY HISTORY:

Not relevant

PERSONAL HISTORY:

DIET : MIXED (Stopped eating non veg since 5months on  doctors suggestion.doctor told him to eat fish n egg but he refused to eat that too since 5 months)

APPETITE:Normal (eating less in quantity due to fear of abdominal distension)

SLEEP: Adequate

BOWEL N BLADDER : Regular

 MOVEMENTS

ADDICTIONS :Had a habit of taking alcohol since 20 yrs ( gudumba 180 ml per day ) .On abstinence since 5 months on suggestion of doctor.

Not a smoker

Daily routine: Wakes up at 5 am and freshen up to go to work at 6:am as he's working as an organiser(sweeps etc) at gram panchayat(he stopped going to field work since 3 months due to above complaints).Works upto 9 am then have his breakfast and takes rest thn  have his lunch and takes rest for 2 hrs and then he roams the street in the evening and then reaches home and eats his dinner at around 7 pm and then goes to bed at 7:30pm - 8:00pm  . 

DRUG AND ALLERGIC HISTORY:

None

GENERAL EXAMINATION: 

Patient is conscious, coherent, cooperative and well oriented to time place person and moderately built and moderately nourished.

Pallor - Absent 

Icterus- PRESENT


Cyanosis- Absent 

Clubbing- Absent 

Lymphadenopathy- Absent 

Pedal edema- Present (pitting type) 

16/6/2023now the pedal edema is mild compared to before

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 

Duptyrene contracture - present on left hand

Petechiae, purpura not seen 

No testicular atrophy

Vitals:

Temp- Afebrile 

Pulse - 75 bpm

Bp - 100/80 

Rr- 18 cpm 

 

SYSTEMIC EXAMINATION

ABDOMINAL EXAMINATION

INSPECTION: 

SHAPE: Abdomen is distended with flank fullness 


SKIN OVER SURFACE :  normal 

No scars,engorged veins ,visible pulsations, peristalsis,discolouration over skin 

Umbilicus : inverted 

PALPATION : 

No local rise of temperature and tenderness

No organomegaly. 

Liver and spleen non palpable 

Abdominal girth: 85cm(after Paracentesis)


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 symmetrical chest expansion 

PERCUSSION: 

Resonant in all areas

AUSCULTATION: no added breath sounds

CVS EXAMINATION:

INSPECTION : 

Shape of chest symmetrical 

No engorged veins , no scars, no visible pulsations 

JVP -normal

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 :

13/6/2023:


Abdominal Paracentesis was done on 16/6/2023 - 1000ml was collected


Xray
 
Saag 


Ascitic fluid sugar , protein 


Ascitic fluid LDH



Blood sugar 

 
Blood urea 



Serum creatine 


Serum electrolytes 


Liver function tests 


Aptt 


Pt,Inr 


Hemogram 

Treatment :

Tab ALDACTONE 50 mg PO/OD
Tab PAN 40mg PO/OD
Syrup LACTULOSE 30ml PO/HS in 1 glass of water
Syrup POTKLOR 15ml in 1glass water PO/BD
Injection Vitamin K 10mg IV/OD
BP, RR, PR monitoring 2 hourly.

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

Comments

Popular posts from this blog

CBBLE PAJR PARTICIPATORY LEARNING ACTION RESEARCH

65 yr old patient with pain in lower abdomen and Shortness of breath

A 14yr old girl came to opd with complaints of Shortness of breath