A 60yr(M) chronic Alcoholic with Abdominal Distension

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT

Complaints-

A 60yr old male came with complaints of           -abdominal distension                

-decreased urine output           since 4 months

-Swelling of B/L lower limbs 

HOPI -

Patient was aparently asymptomatic 4 months back.He then developed abdominal distension which was insiduous in onset , gradually progressive associated with pain abdomen- squeezing type in umbilical region , aggravted on taking food  with no releiving factors .

H//O decreased urine output since 4 months 

H/O EDEMA  in B/L lower limbs - Pitting type  extending upto knee level with no aggravating pr releving factors.

H/O SOB on exertion - Grade 3 MMRC

H/O Fever since 10 days - low grade , intermittent associated with chills and rigors and releived by medication .

H/O Burning micturition since 1 month

H/O cough with expectoration since 4 to 5 days whitish sputum, non blood tinged.

No H/O  Nausea, vomitings , Chest pain, palpitations, Giddiness , Sweating

Past History- 

No similar complaints in the past

K/C/O Type 2 DM and HTN  since 1year 

Not om regular medication.

N/K/C/O - TB, Asthma, Epilepsy, CVA, CAD, Thyroid disorders.

Treatment History- H/O Blood Transfusion done 3 months back -uneventful

Personal History- 

Diet- Mixed

Appetite- Decreased since 2months

Bowel & Bladder Movements-H/O Constipation since 1 month ( passing stools once in  3 days) &Decreased urine output since 4months and burning micturition since 1month

Sleep - Adequate

Addictions - Chronic Alcoholic Since past 40 years consumed around 90 to 120ml/day

 H/O Smoking since past 35yrs 

Family history- Not Significant

GENERAL EXAMINATION-

Patient is Conscious, Coherent and Co operative .

Pallor present

Pedal Edema - Present Pitting type 

No signs of  ,Icterus Clubbing, Cyanosis, Lymphadenopathy

Vitals-

TEMP: Afebrile 

BP: 140/70mmHg

PR: 102 bpm

RR- 24cpm

Spo2- 96% @RA

GRBS:485mg/dL

Systemic Examination:

CVS: Inspection

Chest wall is bilaterally symmetrical.

No precordial bulge is seen 

Palpation

JVP- Normal

Apex beat -felt in the left 5th intercoastal space in the mid clavicular line 

Auscaltation-

S1&S2 are heard,no murmur found.

RESPIRATORY SYSTEM

Position of trachea- central

Bilateral air entry, normal vesicular breath sounds are heard.

No added sounds

CNS

Patient is conscious ,coherent and co operative , well oriented to time and space.

Speech normal.

No signs of meningeal irritation.

Motor and sensory system- Normal

Reflexes - present

Cranial nerves - intact

PER ABDOMEN

On inspection:

Abdominal distention - Present

Abdominl Girth 85cms

All quadrants are moving equally with respiration

Umbilicus - central and inverted

Engorged Veins present

No scars, prominent Venous pulsations and visible peristalsis.

On palpation::

Superficial palpation- No Local rise in temperature and no tenderness

Deep palpation- No guarding, rigidity

On percussion::

Tympanic note - heard 

Shifting Dullness present

On auscaltation::

Bowel sounds heard 

Provisional Diagnosis- 

Chronic liver disease with Portal Hypertension and Anemia.

Investigations

RBS

PLBS -

LFT-07/07/2023

LFT- 09/09/2023

SERUM IRON 

Lipid Profile

Hemogram -7/07/2023

8/07/2023

280ml of PRBC transfusion done (Uneventful)

Hemogram - 9/07/2023 

Hemogram- 10/07/2023

Blood Grouping

Reticulocyte count 

APTT -07/07/2023

APTT- 09/07/2023

PT-INR

Serology

Ascitic Tap done on 8/07/2023 -1L of ascitic fluid collected.

Ascitic Fluid for LDH

SAAG

RFT

Serum Electrolytes -10/07/2023

UKB

CUE

ECG

2DEcho - 

Chest Xray - PA view

USG Abdomen

Treatment- 

1.Inj- HAI 6units IV/STAT

2.Inj.HAI  SC/TID 

3.Tab.LASIX 40mg PO/BD

4.Tab.PCM 650mg PO/OD

5. GRBS monitoring .