50 M with Abdominal distension, shortness of breath since 1 week

This is a case of 50 year old male who is government servant came to the opd with chief complaints of

• Abdominal distension with pain abdomen since 1 week
• Loss of appetite since 1 week
• Shortness of breath since 1 week
• B/L lower limb swelling since 5 days 
• Decreased urine output since 5 days
• Reddish yellowish discoloration of urine since 5 days 

Patient was apparently asymptomatic one week back then he noticed abdomeninal distention which was diffuse associated with abdominal pain( squeezing type ) not associated with vomotings , loose stools ,fever Aggravated with food intake 

Complaints of bilateral pedal edema which is pitting type gradually progressive , extending from ankle to knee joint 

C/o decreased urine output and yellowish discolouration of urine since 5 days not associated with fever with chills and burning miturition , frothing of urine 

No h/o chest pain , palpitations , excessive sweating . 

Complaints of shortness of breath with grade II which is decreased in supine position 

No H/o hematemisis , melena

PAST HISTORY 

History of dengue 3years ago for which he was hospitalized for 15 days 

History of jaundice  2 years ago for which he was transfusions  2 prbc 

No similar complaints in the past 

no history asthma,epilepsy,thyroid disorders,TB 

No history of previous surgeries

FAMILY HISTORY : No significant history 

PERSONAL HISTORY  

DIET : mixed 

APPETITE: Decreased 

BOWEL MOVEMENTS: normal 

Bladder movements: decreased urine output since 5 days  

SLEEP : adequate  

Addictions : Alcoholic since 12 years,he used drink 180 ml of whiskey twice a week but from last 6 years he began drinking 180 ml of whiskey daily, but stopped drinking 15 days ago.

DAILY ROUTINE :

He is a government servant ,field worker in revenue department who wakes up at 5 am completes his daily routine and  goes to work but most of the times he skips his breakfast . Eats lunch in between 2 - 4 pm because  of his busy schedule and goes to bar at 6 pm  to drink alcohol daily ( whiskey 180 ml ) and then goes home and eats dinner at 8pm and sleeps by 10 pm.

GENERAL EXAMINATION 

Patient was conscious,coherent  cooperative

Moderately build and moderately nourished

Pallor : present

Icterus: absent

clubbing: absent

cyanosis: absent

Lymphadenopathy: absent

Edema : absent

VITALS:  

On 3/1/23 

Temp:  afebrile 

BP : 110/70 mmHg supine position 

Pulse : 92 bpm 

RR : 20cpm 

Grbs : 101 mg /dl 

On 2/1/23 

Temp :  afebrile 

BP :  110/90 mmHg 

Pulse :  90 bpm 

RR :  22cpm 

Spo2 : 98%

SYSTEMIC EXAMINATION 

Respiratory system : 

On inspection : 

Shape of chest is normal 

Looks like symmetrically expanding 

No scars and sinuses 

Trachea is central 

On palpation : 

no local raise of temperature or tenderness 

All inspectory findings were confirmed 

On percussion 

Purssion note is same on both sides 

On auscultation :

Bilateral air entry was present 

Crepitus was heard in the right and left inframammary, supra mammary , infra axillary areas

CVS : 

S1 S 2 heard apex beat felt at 5 inter coastal space lateral to mid clavicular line no murmors 

Per abdomen : 

On Inspection :

Abdomen is distended 

Visible veins are seen 

A rash is seen below the xiphoid process 

Umbilicus : flat 

Palpation 

No local raise of temperature 

Abdomen is tense

Percussion - dull note 

Bowel sounds -absent

CNS examination 

HIGHER MENTAL FUNCTIONS:

Conscious, coherent, cooperative

Appearence and behaviour: 

Emotionally stable

Recent,immediate, remote memory intact

Speech: comprehension normal, fluency normal

CRANIAL NERVE:

All cranial nerves functions intact

SENSORY FUNCTIONS

SPINOTHALAMIC TRACT

Pain , temperature ,presure- intact in all limbs

Posterior column:

Fine touch, vibration and proprioception are intact

MOTOR SYSTEM :  

                      Right          Left 

Bulk:  

Inspection.      N.              N 

Palpation.        N.             N 

Tone:  

UL.                  N.               N 

LL.                    N.             N

REFLEXES 

         B      T      S      K        A         P 

R      +       +       +       +       +        Flexor 

L       +      +      +       +         +        Flexor

CEREBELLUM:

Finger nose In coordination - No 

Knee heel in coordination  - No 

CLINICAL IMAGES 

INVESTIGATIONS 

Diagnosis: Decompensated liver disease,  pancreatitis secondary to alcohol intake.

Treatment

Ascitic tap was done but no fluid was drained

•  Fluid restriction  less than 1.5 L /day

• Salt restriction  less than 2g/day

• Inj Lasix 40mg IV BD 

• Syp lactulose 30ml PO 

• Maintain 2-3 times passage of stools

• TAB Gabapentin 100mg PO BD

• Inj Monocef 

• TAB Aldactone 50 mg PO OD