A 45year old Male with Abdominal distension and pedal edema

 

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CASE:

A 45 year old male complaints of abdominal distension and bilateral pedal edema, shortness of breath and scrotal swelling

 

CHIEF COMPLAINTS:

Abdominal distension 

Bilateral pedal edema 

Shortness of breath 

Scrotal swelling 

           Since 25 days

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 6 years back then he had complaints of multiple swellings over chest for which he went to hospital and was diagnosed as diabetic and was started on medication for DIABETES,since then....

2 years back when he went for routine checkup he was diagnosed as hypertensive and started taking medication 

6 months back patient became unresponsive and speech was reduced and was taken to local hospital where he was found to have low Grbs (27mg/dl ) and also found to have jaundice and was advised to stop alcohol consumption 

Then 25 days back he developed scrotal swelling , pitting type of pedal edema above the knee and abdominal distension which was insidious in onset and gradually progressive 

He also complained of shortness of breath on exertion since 20 days which progressed now

PAST HISTORY:

Known case of HYPERTENSION - TAB.Telma 40mg since 2 years

Known case of DIABETES MELLITUS since 

6 years-TAB.glibenclamide 5mg + metformin 500mg 

Stopped taking medication since 6 months 

FAMILY HISTORY:

Insignificant

PERSONAL HISTORY:

Diet :-  mixed 

Appetite :- normal 

Sleep :- adequate (8 hrs per day)

Bowel and Bladder :-regular 

Addictions :-

 chronic alcoholic since 20years -360ml per day stopped drinking since 1 month 

Chronic smoker since 30 years - 2 packs per day 

Occupational history :- hotel owner

GENERAL EXAMINATION:

Patient is conscious coherent and cooperative well oriented to time place and person 

Height :- 158cm 

Abdominal girth :- 124cm 

Vitals:

Temperature :- afebrile 

Pulse rate :- 90bpm

Respiratory rate :-  22

BP :- 130/80

SpO2 :- 98

Pallor,cyanosis, clubbing, are absent.

Edema-pitting type of pedal edema

Icterus :-  present

SYSTEMIC EXAMINATION:

Abdominal examination:

Inspection: 

Abdominal distension 

Umbilicus everted 

Engorged veins present 

No visible peristalsis 

No scars , sinuses 

Palpitation:

Soft non-tender 

no hepatomegaly or splenomegaly 

Percussion : 

Fluid thrill absent

Shifting dullness 

Auscultation:

Bowel sounds heard

CVS: s1 s2 heard no murmurs present 

Respiratory: bilateral normal vesicular breath sounds are present 

CNS: no focal neurological deficit’s are present

 

INVESTIGATIONS:

On 27/10/2022

HEMOGRAM:

HAEMOGLOBIN 10

TOTAL COUNT:6500

NEUTROPHILS:68

LYMPHOCYTES:20

MONOCYTE:10

BASOPHILE:00

PCV:31.5

MCV:114.1

MCH:37.7

MCHC:33

On 29/10/2022

APTT:

BLOOD UREA:

SERUM ELECTROLYTES:

On 27/10/2022:

On 29/10/22:

LIVER FUNCTION TEST:

On 27/10/22:

On 29/10/22:

PROTHROMBIN TIME:

COMPLETE URINE EXAMINATION:

SERUM CREATININE:

SAAG:

ASCITIC FLUID AMYLASE:

ASCITIC FLUID PROTEIN SUGAR:

ASCITIC FLUID LDH:

CHEST X-RAY:

USG ABDOMEN:

2D ECHO:

Provisional diagnosis:

CHRONIC LIVER DISEASE with portal hypertension 

Treatment: 

1)Tab Lasix 80 mg po OD 

2)Tab Aldoctone 50mg BD

3)Tab Lactulose 20ml ODHS