50yr old male with abdominal distention

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I would like to thank Dr. Keerthi for providing with the case details.

CASE PRESENTATION:

50 year old male, farmer by occupation, resident of Pochampally, came to Medicine OPD with complaints of :

* Abdomen distention  since 4 days 

* Pedal edema  since 3 days

* Pain abdomen since 2 days 

HISTORY OF PRESENT ILLNESS: 

The patient was apparently asymptomatic 6 months ago then he developed jaundice and was treated at a private practitioner.

Later he developed abdominal distension about 4 days ago - insidious in onset, gradually progressive to the present size - associated with 

• Pain in epigastric and right hypochondrium - colicky type.
• No H/o fever,  No night sweats.
• Not associated with Nausea, vomiting, loose stools 
• No history of hematemesis, dilated veins, hemorrhoids.
• No history of facial puffiness. 

There was pedal edema 

• Bilateral 
• Pitting type
• 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 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

PAST HISTORY: 

No history of similar complaints in the past 

Patient is not a known case of Diabetes mellitus, Hypertension, Tuberculosis, Asthma, Epilepsy, Thyroid disease.

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 : Patient is a chronic smoker and smoked 4-5 bidis per day since past 30 years (Pack years=Number of cigarettes per day x years of smoking/20; Number of bidis = Number of cigarettes/4; Therefore, Number of Pack years=5/4 x 30/20 = 1.88)

 - 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

Pedal edema - present - bilateral pitting type (grade -2)                 

https://youtube.com/shorts/0tsxfSYduUA?feature=share

No pallor, icterus,cyanosis, clubbing, lymphoedenopathy.

Vitals : 

Temperature- febrile

Respiratory rate - 16cpm

Pulse rate - 90 bpm

BP - 120/80 mm Hg.

SYSTEMIC EXAMINATION: 

CVS : S1 S2 heard, no murmurs

Respiratory system : normal vesicular breath sounds heard.

Abdominal examination: 

INSPECTION : 

        Abdomen is distended.

• Umblicus - everted
• Movements of abdominal wall - moves with respiration 
• Skin is smooth and shiny;
• No scars, sinuses, distended veins, striae.

PALPATION : 

No local rise of temperature.

Tenderness present - epigastrium.

Tense abdomen 

Guarding present

Rigidity absent 

Fluid thrill  is positive 

No hepatomegaly 

No spleenomegaly 

Kidneys not palpable 

Lymph nodes not palpable 

PERCUSSION: 

Liver span : not detectable 

Tympanic note is heard in midline of abdomen 

Dull note heard on the flanks 

Shifting dullness : Positive 

Fluid thrill: felt 

https://youtube.com/shorts/OAFLyW9GFsE?feature=share

AUSCULTATION: 

Bowel sounds: heard in the right iliac region 

No bruits heard 

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:

 Hemogram :

Hemoglobin : 9.8 g/dl

TLC : 7,200

Neutrophils : 49%

Lymphocytes : 40%

Eosinophils : 1%

Basophils : 0%

PCV : 27.4%

MCV : 92.3 fl

MCH : 33 pg

MCHC : 35.8%

RDW-CV : 17.6%

RDW-SD : 57.8 fl

RBC count : 2.97 millions/mm3

Platelet count : 1.5 lakhs/mm3

Smear : Normocytic normochromic anemia

Serology: 

HIV - negative 

HCV - negative 

HBsAg - negative 

Ascitic fluid:

Protein : 0.6 g/dl

Albumin : 0.34 g/dl

Sugar : 95 mg/dl

LDH : 29.3 IU/L

SAAG : 2.66 g/dl

Ascitic fluid Cytology :

- No atypical cells seen .

- Negative for malignancy. 

Ascitic fluid culture and sensitivity

 - No acid fast bacilli seen 

  -No growth after 48hrs of aerobic

  incubation.

USG:

-Coarse echotexture and irregular surface of liver - Chronic liver disease

-Gross ascites

-Gallbladder sludge

Chest X-ray :

ECG :

PROVISIONAL DIAGNOSIS: 

Acute decompensated liver disease/Alcoholic liver  with gross  ascites.

TREATMENT: 

-Abdominal girth charting - 4th hourly

-Fluid restrictriction less than 1L per day

-Salt restriction less than 2 gms per day

Drugs :

1. Inj. Pantoprazole 40 mg IV OD

2. Inj. Lasix 40 my IV BD

3. Inj. Thiamine 1 Amp in 100 ml IV TID

4. Tab. Spironolactone 50 mg BB

5. Syrup Lactulose 15 ml HS

6. Syrup Potchlor 10ml PO TID

Ascitic fluid tapping:

 Done twice on (2-6-2022 & 6-6-2022)