50 year male with abdominal distension

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CHIEF COMPLAINTS

Abdominal distension since 3 months

Shortness of breath since 3months

Pedal edema since 3 days

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 4 months ago, then he developed yellowish discolouration of eyes ,intermittent and reappeared again since 4days not associated with itching,discolouration of urine or stool

Abdominal distension  which was insidious in onset , gradually progressive in nature since 3months,not associated with pain abdomen.

He complained of shortness of breath since 3months (grade 2) upon doing ordinary activity like walking to his field after eating.He used to walk 2km without any inconvenience but since 3 days he is able to walk upto 1km only. He also complained of pedal edema since 3days which was insidious in onset, gradually progressive and confined upto ankles( grade 1) and pitting type.

H/O decrease in urine output since 3 days and difficulty in passing stools and passing hard stools since 3 days which relieved on taking medication.

H/ O yellowish discolouration of eyes  on and off since 4months

No H/O blood in urine, burning micturition, increased frequency and urgency.

No H/O orthopnea, paroxysmal nocturnal dyspnoea

No H/O abdominal pain, nausea ,vomiting, dark stools and diarrhoea.

No H/O chest pain, palpitations, facial puffiness

No H/O fever, chills, rigor, myalgia, joint pain and  rashes.

No H/o any blood transfusions

No H/o any bleeding manifestations 

3 months back diagnosed as decompensated liver disease for which he was treated here and he continued taking medication since discharge and stopped taking them since two days before developing the recent symptoms.

Endoscopy was done here 3 months back and oesophageal varices were detected.

PAST HISTORY:

No H/O hypertension, diabetes mellitus, tuberculosis, asthma, coronary artery disease, epilepsy.

No H/O any surgeries.

FAMILY HISTORY

No similar complaints in the family.

PERSONAL HISTORY 

Patient is a 50 year old male hailing from thanamcherla, who is farmer by occupation, married(  consanguineous) at 20 years and has three children.(2daughters and 1 son)

Stays along with his wife and son.

Daily routine : He wakes up at 5'O clock and goes to his 1acre farm by walk, comes back after an hour, eats breakfast and lunch which are rice and vegetable.He takes afternoon nap for one hour, then again goes to his farm for sometime and comes back for dinner and then sleeps.

Sometimes he also goes for work at municipal office and from there to cleaning roads,schools.

Diet : vegetarian, stopped eating non vegetarian foods 3 months back.

Appetite : normal

Sleep : adequate

Bowel movements: decreased

Bladder movements: decreased 

Addictions :  Alcoholic since 30 years but Started drinking more alcohol along with his friends at municipal office,he had been drinking 1litre of sara (Local alcohol) from the last 10-15years, but stopped from past 3 months on doctor's advice.Slowly drinking with his municipal office friends has become his daily routine.

GENERAL EXAMINATION:

Patient is conscious,coherent and co operative, well oriented to time, place and person 

Patient is moderately nourished and moderately built 

Height -5’5

Weight -60kgs

Pallor -present

Icterus -present

Cyanosis- absent

Clubbing - absent

Lymphadenopathy - absent

Pedal edema - present (grade 1,pitting type)

Parotidomegaly+

EXTERNAL MARKERS OF LIVER CELL FAILURE

HEAD AND NECK- No alopecia, no bitots spots, no xanthelasma, subconjunctival hemorrhage, pallor +, icterus+, no medial supraciliary madarosis, sunken eyes and cheeks, loss of facial hair, no parotid enlargement, bleeding gums

TRUNK - no spider nevi, no gynaecomastia, loss of pectoral/axillary hair present, no dilated veins, wasting, abdominal distension present, no caput medusae, no loss of pubic hair, no testicular atrophy, no scratch marks, purpura

UPPER LIMBS - dupuytrens contracture present, no bounding pulse, no clubbing, no flapping tremor, no palmar erythema, no pruritic marks

LOWER LIMBS - Pedal Edema present

NO BONY TENDERNESS, GUM HYPERTROPHY, LEUKEMIA CUTIS

VITALS 

Afebrile 

Blood pressure-110/70mm Hg

Pulse-78bpm,Regular rhythm,normal volume and character and no RR ,RF delay,all peripheral pulses normal

RR-18cpm, abdominothoracic

SYSTEMIC EXAMINATION 

ABDOMINAL EXAMINATION:

INSPECTION-

Abdomen is distended

Umbilicus is inverted

Skin is normal without any scars

No discolouration of skin ,engorged veins,sinuses 

No visible peristalsis or pulsations 

Hernial orifices Normal 

Movements of abdominal wall equal in all quadrants with respiration 

External genitalia normal

PALPATION-

Superficial palpation:Abdomen is non tender and no local rise in temperature 

No guarding and rigidity 

Deep palpation:Palpation by dipping method -No organomegaly 

PERCUSSION-

liver :Upper border of liver dullness is percussed at the right 6th ics along mid clavicular line and lower border cannot be palpated

Spleen:cannot be palpated

No fluid thrill  

shifting dullness present

AUSCULTATION-

Bowel sounds heard 12/min

No bruit or venous hum

PER RECTAL:stool stained

CNS EXAMINATION:

No flapping tremors

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5 in all limbs

Reflexes: Right. Left. 

Biceps. ++. ++

Triceps. ++. ++

Supinator ++. ++

Knee. ++. ++

Ankle ++. ++

CARDIOVASCULAR SYSTEM EXAMINATION:

Inspection : 

Shape of chest- elliptical ,bilaterally symmetrical

No engorged veins, scars, visible pulsations

JVP - not raised

Palpation :

Apex beat can be palpable in 5th inter costal space half inch medial to MCL

No thrills and parasternal heaves can be felt

Auscultation : 

S1,S2 are heard

no murmurs.

RESPIRATORY SYSTEM EXAMINATION:

Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

No scars, sinuses, engorged veins, pulsations 

Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: resonant bilaterally 

Auscultation:

bilateral air entry present. Normal vesicular breath sounds heard.

PROVISIONAL DIAGNOSIS 

Decompensated chronic liver disease (Cirrhosis)2° to chronic alcohol consumption with ascites with history of esophageal varices without any upper GI bleed with no evidence of hepatic encephalopathy,Spontaneous bacterial peritonitis or other complications 

INVESTIGATIONS

USG ABDOMEN:

Irregular coarse echotexture of liver 

Mild splenomegaly 

Gross ascites s/o chronic liver disease 

 

ECG

CHEST X RAY

ECHO

No RWMA,Good LV systolic function,No PAH

HEMOGRAM :

Hb-9.5g/dl

TLC-8,800cells/cumm

Platelets-1.71lakhs/cumm

PBS-normocytic normochromic anemia

LFT

Total bilirubin-1.65mg/dl

Direct bilirubin-0.25mg/dl

AST-20IU/L

ALT-11IU/L

ALP-205IU/L

Total protein 5.9gm/dl

Albumin -2.0

A/G-0.54

RFT-

Urea-14

Serum creatinine-0.9

Na+ 136

K+ 3.4

Cl- 102

PT-19sec(PTc-10-16sec)

INR-1.4

APTT-39sec(APTTc-24-33sec)

Rapid HCV Negative

Rapid HBV Negative

Ascitic fluid analysis

Cell count -100cells/cumm,100% lymphocytes

Glucose-165

Protein-1.0

Serum albumin-2.0

Ascitic Albumin-1.0

SAAG-2

Gram stain-No growth

Culture and AFB negative

Endoscopy:Grade 4 esophageal varices

Final diagnosis-Chronic Decompensated liver disease secondary to alcohol with features of portal hypertension such as ascites,esophageal varices,Splenomegaly with no evidence of hepatic encephalopathy,SBP

Treatment:

1.Fluid restriction 

2.Salt restriction 

3.Therapeutic paracentesis done-1litre

4.Tab LASIX 40mg BD

5.Tab aldactone 50mg BD

6.Syrup Lactulose 20ml PO TID

Child Pugh score -9, Grade B with one year survival at 80% and 2 year survival at 60%.

Counselled about liver transplantation