48 year old male with abdominal distension

  Dr.N.Deepa , Internee

Roll no. 105

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

Date of admission : 19/04/2023

CASE : 

A 48 year old male, auto driver by occupation came to the opd with chief complaints of 

- Abdominal distension since 20 days

- Bilateral pedal edema since 15 days

- Decreased urine output since 10 days

- Shortness of breath since 10 days

-Blood in stools since 5 days

- Loose stools since 4 days

HOPI : 

Patient ws apparently normal 20 days back.Then he developed abdominal distension which was insidious in onset and gradually progressed to present size.

No complaints of pain abdomen.

He developed bilateral pedal edema since 15 days which is pitting type and extending till the knee joint.

He has decreased urine output since 10 days.

No complaints of burning micturition.

History of shortness of breath since 10 days, insidious in onset, gradually progressed from grade 1 to grade 3 .SOB increased on exertion and relieved on taking rest.No orthopnea .No PND.

He gave history of blood in stools since 5 days -- blood at the end of defecation.

Not associated with pain ,no mass per rectum.

History of loose stools since 4 days,4-5 episodes per day.

No history of fever, vomiting,chest pain,giddiness.

PAST HISTORY : 

History of jaundice in the past- 2 years back and 6 months back and was managed conservatively with medication.

K/c/o Hypertension since 10 years, initially was on T.TELMA 80 mg which was later reduced to T.TELMA 40 mg and now the patient is on T.AMLONG 5mg + ATENOLOL 50mg PO OD

N/k/c/o DM-2,TB,CAD,CVD

PERSONAL HISTORY :

Diet : Mixed

Appetite : Decreased since 20 days

Bowel and bladder movements : Decreased                                                 urine output 

Sleep : Adequate 

No allergies

He is  alcoholic since 25 years.

FAMILY HISTORY :

No history of diabetes or hypertension in the family.

GENERAL EXAMINATION :

Patient is examined in a well lit room after taking the consent. 

He is conscious, coherent and cooperative. 

Well oriented to time, place and person. 

Pallor - absent                   

Icterus - present

Cyanosis - absent

Clubbing - absent

Generalized Lymphadenopathy - absent

Bilateral pedal edema - present

Pitting edema extending till the knee joint.

VITALS :

Pulse - 76 beats per minute, regular in rhythm, normal in volume and character of vessel, no radio- radial delay, no radio - femoral delay. 

Respiratory rate - 20 cycles per minute

Blood pressure - 110/70 mm of hg, measured in the left arm in supine position

Temperature - afebrile 

Spo2 - 98% at room air

GRBS - 94 mg/dL 

SYSTEMIC EXAMINATION : 

CVS : 

    

S1 S2 heard, no murmurs

CNS : 

No neurological deficit

RS :

Bilateral air entry present,no adventitious sounds.

ABDOMINAL EXAMINATION : 

Inspection - abdomen distended 

                      Umbilicus is flat and central

                      No visible scars or sinuses

                      No visible gastric peristalsis

                      

Palpation - No local rise of temperature

                     No tenderness

                     Organs couldn't be palpated

Percussion - fluid thrill present

Auscultation - bowel sounds normal

INVESTIGATIONS : 

Investigations sent on 19/4/2023

2D echo

Ultrasound abdomen:

Ascitic tap was done ( diagnostic and therapeutic tap)

Investigations sent on 22/4/2023

DIAGNOSIS : 

•DECOMPENSATED CHRONIC LIVER DISEASE 

•INTERNAL HAEMORRHOIDS SECONDARY TO PORTAL HTN 

• GRADE 4 OESOPHAGEAL VARICES

TREATMENT : 

Day 1 (19/4/2023):

• Inj.THIAMINE 200mg in 100ml NS IV OD 

• Tab.UDILIV 300mg PO BD 

 •Tab.ALDACTONE 50mg PO OD

• Inj.PAN 40 mg IV OD

• Tab.SPOROLAC DS PO TID

• ORS sachets - 2 sachets in 1 litre of water and 200ml after each episode 

• Protein powder in a glass of milk

• Monitor vitals,input and output, Abdominal girth.

Diagnostic and therapeutic tap was done and around 800ml of ascitic fluid was drawn.

 Day 2 (20/4/2023) : 

Loose stools subsided

Abdominal girth 102cm -------99cm

Weight 70kgs -----69kgs

Psychiatry referal was done i/v/o alcohol dependence

Patient is psychoeducated and Tab.Pregabalin 75 mg is advised.

Surgery referral done i/v/o blood in stools

and the patient is diagnosed to have internal haemorrhoids secondary to portal hypertension,advised banding or sclerotherapy if bleed continues or if there is significant drop in haemoglobin.

• Inj.THIAMINE 200mg in 100ml NS IV OD

•Tab.UDILIV 300mg PO BD 

 •Tab.ALDACTONE 50mg PO OD

• Inj.PAN 40 mg IV OD

• Tab.PREGABALIN M 75mg PO HS

•Protein powder 2tbsp  in a glass of milk

• Monitor vitals,input and output, Abdominal girth.

• Restriction of fluids <1.5lit/day

Day 3 ( 21/4/2023) : 

Endoscopy was done and diagnosed to grade 4 oesophageal varices

•Tab.UDILIV 300mg PO BD 

 •Tab.ALDACTONE 50mg PO OD

• Inj.PAN 40 mg IV OD

• Tab.PREGABALIN M 75mg PO HS

•Protein powder 2tbsp  in a glass of milk

• Monitor vitals,input and output, Abdominal girth.

• Restriction of fluids <1.5lit/day

Therapeutic ascitic tap was done and around 500ml of fluid was drawn.

Day 4 (22/4/2023): 

• Inj.NORAD 4mg in 46ml NS @4ml/hr

• Tab.UDILIV 300mg PO BD 

 •Tab.ALDACTONE 50mg PO OD

• Inj.PAN 40 mg IV OD

• Tab.PREGABALIN M 75mg PO HS

•Protein powder 2tbsp  in a glass of milk

• Monitor vitals,input and output, Abdominal girth.

• Restriction of fluids <1.5lit/day