MEDICINE CASE DISCUSSION

• Roll no
• 202
• 205
• 208
 DEMOGRAPHIC
DETAILS
• Name : Mr. X
• Age :47 years old
• Sex - Male
• Resident of Sadar Bazaar, New Delhi
• Religion- Hindu
• Education : No formal education

• Occupation : Cardboard box manufacturer

• SES- Middle by Modified Kuppuswamy Scale
• Date of admission : 9th August 2021
 CHIEF
COMPLAINTS
Patient presented to LHMC emergency on 9th August 2021 with chief

complaints of :

• Yellowish discoloration of eyes X 6 months

• Abdominal distensionX 5 months

• B/l lower limb swelling X 3 months

• Abdominal pain X 15 days

 HISTORY OF PRESENT
ILLNESS
• Patient was apparently well 5 months back, when he
noticed abdominal distension. It was insidious in onset,
gradually progressive in nature ; initially involving flank
region then umbilicus and later involving the entire
abdomen.
• Patient gives history of usage of 3 pillows under
his back because he has difficulty in breathing on lying
down.
• Patient also noticed swelling of lower limbs 3 months back
noticed as markings of his slippers over his right foot, which
was insidious in onset, gradually progressive. After about a
week it appeared on left foot also, which has progressed to
present till the level below bilateral knee .
• Limb swelling was not a/w postural variation
• Not a/w diurnal variation
• Not a/w frothy urine, decreased urine output,
blood in urine
• No history of weight gain
• No h/o chest pain, palpitations
• No h/o Vomiting of Blood (hematemesis)
• No h/o passage of black, tarry,sticky, foul
smelling stools (Melena)
• The patient also complained of yellowish discolouration
of eyes and passage of dark coloured urine for last 6
months.
• H/o reduced appetite
• No h/o generalized itching
• No h/o passage of clay colored stools
• H/o blood transfusion 8 years back ( reason not
known )
• H/o tattooing in childhood.
• No h/o iv drug abuse
• No h/o multiple sexual partners
• No h/o skin rash, joint pain
• H/o altered sleep pattern. Patient has disturbed sleep.
He sleeps 2-3 hours at night and has increased
daytime sleepiness
• No h/o breathlessness
• The patient also complained of abdominal pain
for last 15 days which was generalized dull
aching in character, insidious in onset, present
over the entire abdomen, non radiating,
aggravated on coughing and bearable by the pt.
• No h/o night sweats
• No h/o constipation, diarrhoea
 PAST
HISTORY
•No h/o episode (s) of jaundice or
hospitalization due to same
• Currently not on any medications
• No h/o TB, asthma, DM, HTN, COPD,
seizure
• No history of abdominal surgery
 PERSONAL
HISTORY
• Non vegetarian
• Normal bowel and bladder habits.
• H/o altered sleep pattern. Patient has disturbed sleep. He sleeps
2-3 hours at night and has increased daytime sleepiness
• H/o decrease appetite since one week(4 rotis at a time to 1
roti).
• Non smoker
• Consumes 180 ml of whiskey daily since 20 years
 FAMILY
HISTORY
• No similar complaints in the family.
• No h/o jaundice in any family member.
• No h/o tuberculosis , diabetes mellitus, hypertension,
asthma in any family member
 SUMMAR
Y

•My patient 47 year old male who is a chronic alcoholic presented to LHMC emergency
with complaints of abdominal distention for last 5 months, yellowish discolouration of
eyes for last 6 months, insidious in onset and gradually progressive,with h/o difficulty
in breathing on lying down, B/L lower limb swelling for last 4 months, with h/o
Reduced appetite,Blood transfusion 8 years back and tattooting in childhood ,
abdominal pain Altered sleep pattern.
 DIFFERENTIAL
DIAGNOSIS
(based on history)
• Chronic liver disease
- Alcoholic etiology
- Viral etiology
• Abdominal tb

• (Right heart failure)

• (Constrictive pericarditis)
• (Nephrotic syndrome)
EXAMINATION
 GENERAL PHYSICAL
EXAMINATION
• Patient was conscious and well oriented to time, place and person. He was
lying comfortably on the bed with 2- 3 pillows under his back.
Consent was taken before examination and examination was
done in a well lit room.
• BMI= 20.3kg/sq meters
• Pulse = 82/min taken in right radial artery, regular rhythm, no radio-radial delay,
no radio-femoral delay, vessel wall was not palpable, all peripheral pulses were
palpable.
• BP- 110/80mm Hg taken in the right arm in sitting position.
• RR=30/min, regular, abdomino-thoracic breathing.
• Temperature = 99.8oF (taken orally)
 HEAD TO TOE
EXAMINATION
• HAIR – sparse, coarse, black, alopecia present
• EYES – icterus present.
• FACE – parotid swelling present
• No cheilosis, angular stomatitis
• TONGUE- Normal colour and texture.
• Cyanosis absent
• GUMS- no bleeding gums.
• Orodental hygiene - poor, no hepatic foetor
• NECK- no visible swelling, JVP not raised.
• Spider naevi not present.
• Gynaecomastia absent
• Skin is dry and coarse.
• Loss of axillary and pubic hair
• NAILS - leuconychia present and clubbing absent.
• No other stigmata of CLD like palmar erythema,
Dupuytren’s contracture, testicular atrophy
• Flapping tremors absent.
• Lymphadenopathy absent.
• B/L asymmetrical edema of lower limbs(R>L), up till knees,
which is pitting in nature.
 PER ABDOMEN
EXAMINATION
• INSPECTION-
• Abdomen appears diffusely distended, flanks are full
• Skin appears to be stretched and shiny.
• All quadrants moving freely and symmetrically with
respiration.
• No visible peristalsis, pulsations.
• Umbilicus is central, everted and displaced downwards
• No visible dilated veins
• No scar, sinus, fistula was seen
• Hernial sites were free on cough impulse

• External genitalia appears normal

 PALPATION
Done in supine position with both limbs flexed and hands by the
side of the body
• Superficial palpation- Abdomen is normal in consistency and
non tender, no guarding or rigidity seen. No local rise of
temperature
• Abdominal Girth
– At umbilicus= 92 cm
– Right and left spinoumbilical length are equal
– Xiphoumbilical distance (= 24 cm) is greater than
Umbilicus to Pubic Symphisis distance (= 19cm)
• Liver and spleen not palpable
• No pulsation/peristalsis
 PERCUSSION
• Liver- Upper border of liver dullness started at 5th
intercostal space in MCL; Lower border could not be
appreciated.
• Spleen- By Castell’s method, resonance observed in 9th
ICS along anterior axillary line
• Shifting Dullness present
• Fluid thrill present
AUSCULTATION
• Normal bowel sounds heard(2-3 sounds/min).
• No venous hum or bruit appreciable
 OTHER SYSTEM
EXAMINATION
• Respiratory system

Trachea was central in position. Chest was

bilaterally symmetrical
Bilateral vesicular breath sounds heard

• Cardiovascular system
S1, S2 heard, no murmurs
Apex beat present in 5th intercostal space
 CNS Examination
• The patient was conscious and oriented to time,
place and person but was restless and irritable
• Responding to voice
• Deep tendon reflexes were intact
• Glasgow coma scale - 14
 DIAGNOSIS

My patient a 47 year old male is provisionally

diagnosed to have chronic liver disease
probably of alcoholic etiology with
decompensated cirrhosis with hepatic
encephalopathy ( grade 1) and ascites
D/D POINTS IN FAVOUR POINTS AGAINST

Alcoholic LIVER History -jaundice 1. HISTORY- edema

DISEASE WITH Ascites started on feet first
DECOMPENSATED then appeared on
CIRRHOSIS. Cirrhogenic dose of abdomen
alcohol
Examination-
icteric
tinge in eyes

Chronic liver disease A. History-tattooing No history of iv drug

with decompensated Blood transfusion abuse, multiple
cirrhosis due to viral sexual partners.
etiology
D/D POINTS IN FAVOUR POINTS AGAINST

3. CHF Edema started on feet No other signs of heart

first and then progressed failure
to abdomen

History of orthopnea

4. AbdominalTB Fever, abdominal pain No history of evening rise

Loss of appetite of temperature, weight
Ascites loss, night sweats
Non tender abdomen on
palpation
 INVESTIGATI
ONS
• CBC with platelet count, ESR
• LFT ,KFT, PT-INR
• USG adomen
• Ascitic tap(SAAG)
• ASA, ZN staining
• Chest x ray
• Viral markers - HBV- HbS Ag, HbE Ag, HCV
markers
• Upper GI endoscopy
 TREATMENT
Salt restriction (Less than 2g per day)
Fluid restriction(less than 1.5 litre per
day) Iv cefotaxime 2g iv 8 hrly
Metrogyl tab 400mg tds
Inj pantop 40mg w4 hrly
Syrup lactulose 30ml OD
HS Inj albumin 20g OD

Diuretics
- Tab. Spironolactone 50
mg OD
- Tab. Furosemide 20 mg
BD (if needed)
THANK YOU