48 year old male with abdominal distension since 20 days

 

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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.

Case presentation - 

A 48 year old male resident of Chityala , auto driver by occupation came to OPD 

Chief complaints - 

- Abdominal distension since 20 days 

- shortness of breath since 20 days 

- decrease frequency of micturition since 20 days 

- decrease urine output since 3 days 

- blood in stools since 3 days 

History of presenting illness : 

Patient was apparently asymptomatic 20 days back , then he developed abdominal distension , which was insidious in onset , progressive to present size , associated with loss of appetite 

Then he developed SOB 20 days ago , insidious on onset , initially of grade 2 which progressed to grade 3  relived on rest 

Patient complains of decrease in urinary frequency (1-2 episodes / day ) since 20 days , decrease in output since 3 days. Bright red blood discharge ( few drops ) after passing stools . Solid consistency. Not bile stained 

B/L pedal edema extended upto knee , pitting type , relived after walking. No aggravating factors 

No H/o abdominal  pain , fever , constipation , weight loss , nausea , vomiting , dysphasia 

No h/o chest pain , cough , orthopnea , PND , platypnea, palpitations, light headedness , giddiness 

No h/o pain during defecation , burning micturition 

Past history : 

K/C/O of hypertension 

Diagnosed 10 years ago 

Rx : telma ( amlodipine + atenolol ) 

 

Not a K/C/O diabetes , tuberculosis, epilepsy 

Personal history : 

Diet - mixed 

Appetite- decreased 

Sleep - adequate

Bowel movements - increase , blood stained 

Bladder movements - decreased 

Addictions - chronic alcoholic since 13 years 

180 ml whiskey / day

Stopped for 2 years , started again 1-2 years ago 

Last bout of alcohol - April 1st 

General examination : 

Patient was conscious , coherent , cooperative 

Well built , well nourished 

Icterus - present 

B/L pedal edema - present 

No signs of pallor , clubbing , kolionychia , lymphadenopathy 

VITALS 

TEMP - a febrile 

HEART RATE -72bpm

PULSE PRSSURE -130/90mmhg

RESP RATE -16cpm

Systemic examination : 

Per abdomen 

Inspection - 

Shape : distended uniformly 

Dilated veins are seen 

Spider navi is present 

Umbilicus - flattened 

Abdominal movements are equal 

No scars , swellings , visible pulsations 

No stretch marks are seen 

Palpation - 

No local rise of temperature 

No tenderness 

No rebound tenderness 

No palpable swellings 

Liver , spleen - not palpable 

Percussion - 

Shifting dullness - present 

Fluid thrill - present 

Auscultation- 

Bowel sounds - heard 

Cardiovascular system - 

Inspection - 

carotid pulse is seen 

JVP visible on sitting 

B/L chest movements are equal 

Palpations - 

Apical impulse felt : 5th Intercoastal space ; mid clavicular 

Auscultation - 

S1 , S2 heard 

No murmurs 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 ++. ++

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 area 

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.

Vic resonance -reduced on left side mammary ,axillary ,infraaxillary 

Investigations - 

Provisional diagnosis : 

My provisional diagnosis in this patient is acute decompensation of chronic liver disease with symptoms suggestive of portal hypertension