48 year old male with Abdominal Distension

 

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I have 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 diagnosis and treatment plan.

A 48 year old male resident of Chityala Auto Driver by occupation came to OPD with 

CHIEF COMPLAINTS 

Abdominal distension since 20 days  

Breathlessness since 20 days 

Swelling of bilateral lower limbs since 20 days 

Decreased urine output since 3 days 

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 20 days back then he developed abdominal distension which was insidious in onset ,gradually progressed to present size . It is diffuse type of abdominal distension

H/o  Shortness of breath since 10 days initially he used to walk to his home without any problem  after parking his auto at a distance from home.Now he has to take rest after walking such distance (MMRC grade 2) .Distension doesn’t change with position 

No h/o  orthopnea ,PND,abdominal pain ,vomitting ,obstipation .

Swelling of bilateral lower limbs since 15 days insidious in onset , gradually progressive upto knee level, pitting type (grade 2) reduced  on  walking ,no change at rest and raising the legs

No history of chest pain ,palpitations,facial puffiness .

H/o high coloured urine since 20 days associated with decreased urine output since 10 days not associated with burning micturation,pain ,increased frequency and urgency .

H/o yellowish discolouration since 2 years not associated with itching ,pale coloured stools .

No H/o  fever ,headache ,rash ,joint pains ,no history of change in sleep pattern ,confusion ,altered sensorium ,no history of blood in stools, melena ,constipation .

PAST HISTORY 

 

 K/C/O HTN since 10 years 

Not a K/C /O DM,TB,seizures ,heart diseases,thyroid abnormalities,

No history of blood transfusions,tattooing , chronic drug intake . 

FAMILY HISTORY 

No similar complaints in the family  

TREATMENT HISTORY 

T.Telma 80mg initially 

Later was put on T.telma 40mg 

T.amlong 5 mg currently 

Atenolol 50 mg currently 

PERSONAL HISTORY

Diet -mixed 

Appetite -decreased 

Sleep -adequate 

Bowel and bladder -regular ,reduced output 

Addictions -alcoholic since 2007

Consumes 250-350 ml of whiskey everyday after work in the night.

GENERAL PHYSICAL EXAMINATION 

Patient is conscious,coherent and co operative 

patient is moderately nourished and moderately built 

Weight -48kgs 

PALLOR -absent 

ICTERUS -present involving the upper bulbar conjunctiva 

CYANOSIS -absent 

CLUBBING -absent 

LYMPHADENOPATHY -absent 

PEDAL EDEMA -present (Pitting Type)

Head to toe examination:

hair is normal 

No parotid swelling 

Palmar erythema- absent 

Gynaecomastia -absent 

Pale coloured nails -present 

Tremors -absent 

spider naevi -present 

Petechiae,purpurae -absent 

abdominal scars - present (ascitic tap ) 

VITALS 

TEMP -  99.7° F

HEART RATE - 76 bpm

BLOOD PRESSURE - 160/70 mm Hg

RESP RATE - 16 cpm

Per abdomen:

Inspection 

Abdomen is distended in shape , with flank fullness

Umbilicus is everted 

skin is normal 

Spider neavi are present in upper back area 

no discolouration of skin ,engorged veins ,sinuses 

No visible peristalsis or pulsations

Palpation

No local rise of temperature 

No tenderness 

No guarding 

No Rigidity 

No organomegaly 

Percussion 

Liver 

upper border of liver dullness is per used at the right 6 th inter coastal space along the mid -clavicular line on full expiration and the lower border cannot be palpated 

Spleen 

Castell’s method - dullness is observed in 9 th ICS of any axillary line 

 fluid thrill +ve

shifting dullness  +ve

Auscultation 

bowel sounds heard 

CNS examination 

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

Reflexes: Right. Left. 

Biceps. ++. ++

Triceps. ++. ++

Supinator ++. ++

Knee. ++. ++

Ankle ++. ++

CVS examination 

Inspection : 

Shape of chest- elliptical 

No engorged veins, scars, visible pulsations

JVP - raised

Palpation :

 Apex beat can be palpable in 5th inter costal space

No thrills and parasternal heaves can be felt

Auscultation : 

S1,S2 are heard

no murmurs

RESPIRATORY SYSTEM:

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 - reduced on left side in mammary ,axillary and infraxillary areas 

Percussion: stony dullness in left in left mammary ,axillary ,infraxillary areas 

Tidal percussion-resonant note 

Auscultation:

bilateral air entry present. Normal vesicular breath sounds heard

INVESTIGATIONS

Chest x ray - 

Ascitic tap was done and analysis are as follows 

 

DIAGNOSIS : 

Decompensated chronic liver disease.