General medicine final practical short case

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50 year old male, farmer by occupation,  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.

* Decreased micturition since 2 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 hypochondrium  
• Not associated with fever , No night sweats.
• Not associated with Nausea, vomiting, loose stools 

There was pedal edema ( grade 2 )

• Gradually progressive 
• Pitting type
• Bilateral 
• Below knees
• Increases during the day - maximum at evening.
• No local rise of temperature and tenderness 
• 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, he stopped taking alcohol since 6 months When he drank on 29/5/22 ascites has increased.

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 -4 - 5/day since 30 years ;

                           - Alcohol - Toddy - 1 bottle, 2 times a week, since 30 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, lymphoedenopathy.

Vitals : 

Temperature- afebrile

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 not palpable 

Spleen not palpable 

Kidneys not palpable 

Lymph nodes not palpable 

PERCUSSION: 

Liver span : not detectable 

Fluid thrill: felt 

Tympanic note is heard on the midline and dull note is heard on the flanks in supine position

AUSCULTATION: 

Bowel sounds are decreased 

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:

Decompensated chronic liver disease with ascites.

TREATMENT: 

Inj Lasix 40 mg iv BD

Tab spironolactone 50 mg BD

Paracentesis

Syp. Lactose 15ml TID

Abdominal girth charting - 4th hourly

Fluid restrictriction less than 1L per day

Salt restriction less than 2 gms per day