1801006106 - SHORT CASE

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A 30 year old male came who is a resident of chityala came with chief complaints of yellowish discolouration since 2 months bilateral pedal edema since 1 week .

Chief complaints : 

History of presenting illness : 

 Patient was apparently asymptomatic 3 months ago but then he developed yellowish discolouration of eyes , insidious in onset 

gradually progressive since 3months,associated with h/o yellow discolouration of urine.

B/L pedal edema since 1week ,insidious onset ,gradually progressed till knees,associated with abdominal distension which is present since one month .

• Shortness of breath since 1 week,insidious onset ,gradually progressive

•Fever since 1-2days,High grade not associated with chills,relievedwith medication,which was diffuse,non radiating,no aggregating and relieving factors

• loss off appetite and generalised weakness since 2-3days

N h/ o vomitings

N h/o loose stools , vomitings .

Past history 

1 year ago yellowish discolouration of eyes present after which he stopped drinking alcohol for 3 months and later started drinking again 

No history of diabetes , hypertension, tb , ASTHMA , epilepsy, CAD

Family history 

Not significant 

Personal history 

Alcoholic since 5 years drinks about 180ml of alcohol per day

•Non smoker

•Bowel bladder habits regular

•Mixed diet

•Sleep adequate

General examination 

Patient is conscious,coherent,cooperative , patients is thin built.

Vitals :

PR : 130bpm, regular 

Bp: 100/60mmhg

Tempt : 103 F

Spo2 :96% at Room air

•RR:28cpm

•Grbs:128mg/dl

•Jvp normal

Pallor ++ 

Icterus ++ 

X ray :  

Bilateral pleural effusion 

NO cyanosis , clubbing , lymphadenopathy 

pedal edema ++ upto knees , pitting type 

Ecchymosis at the site of canula and at the site of puncture for ascitic fluid 

Investigations :

RFT : 

Urea : 26 

Creatinine : 0.8 

Sodium : 128 

Potassium : 3.0

Hemogram:

Hemoglobin:6.8gm/dl

Total leukocyte count : 13,000cells 

Neutrophils : 86%

LFT :

Total bilirubin : 10.20

Direct bilirubin : 4.20

AST : 161

ALT: 72

Total protein : 6.4

Albumin :1.51

Blood culture : no growth 

Urine culture : no growth 

Serum amylase: 42

Serum lipase : 40

Ascitic fluid :

Cell count : 1570 cells 60% N

Cytology : acute inflammatory smear, negative for malignancy 

Protein : 0.7

Sugar: 46

Albumin:0.21

Culture : no growth 

Pleura fluid :

Cell count: 2550 70% neutrophils 

LDH 641

Total protein : 3.3

Lights criteria : exudative

Culture : no growth 

ECG : 

Systemic examination :

Per abdomen :

INSPECTION: •Shape:Distended

•Umbilicus:inverted,vertically drawn down

•Skin over the abdomen is shiny

•All quadrants are moving equally with respiration

•No visible peristalsis,Hernial orifices intact 

•Visible superficial abdominal vein running vertically down is seen

•External genitalia normal

Palpation:

•Temperature:Not raised

•Tenderness+,diffuse all quadrants

•Rebound tenderness +

•No guarding,rigidity

•Harvey’s sign : flow of blood away from umbilicus above the level of umbilicus and below the level of umbilicus

•No hepatospleenomegaly

Percussion

Shifting dullness +

No fluid thrill

Puddles sign –not elicited

Liver span-12cm

Auscultation

Bowel sounds+

Respiratory system:

Inspection

•Shape of chest:Bilaterally symmetrical,Elliptical in shape

•No visible chest deformities

•No kyphoscoliosis,

•Abdomino thoracic respiration,No irregular respiration

•No tracheal shift

•No dropping of shoulders,Spino scapular distance appears equal on both sides,no sinuses,scars,engorged veins

Palpation:inspectory findings confirmed by Palpation 

•Chest movements -normal

Percussion:

Resonant note heard over all areas except infraaxillary and infrascapular

Auscultation: Norma vesicular breath sounds,Decreased breath sounds in B/L infraaxillary,infrascapular areas

Vocal resonance:Decreased in basal areas

Cardiovascular system:

Inspection:precordium normal,apex beat :5th ICS half inch medial to mid clavicular line

Palpation:inspectory findings confirmed,No thrills or parasternal heave

 Auscultation: S1S2+,no murmurs

 

CNS:HMF normal,cranial nerves intact,motor and sensory examination normal

No cerebellar or meningeal signs

Provisional diagnosis :

Ascites secondary to chronic liver disease 

Bilateral pleural effusion