MEDICAL CASE CONFERENCE

Roll number 2,5,6

 DEMOGRAPHIC DETAILS
• Name : Sanjay Grover
• Age :33 yrs old
• Resident of Sadar Bazaar, New Delhi
• Religion- Hindu
• Education : No formal education
• Occupation : Cardboard box manufacturer
• Date of admission : 29th June 2019
 CHIEF COMPLAINT
• Patient presented to LHMC emergency on 29th
June 2019 with chief complaints of :

• B/l Lower limb swelling X 5 months

• Abdominal distension X 4 months
• Yellowish discolouration of eyes, abdominal
pain and fever X 3 days
 HISTORY OF PRESENT ILLNESS
• Pt was apparently well 5 months back when
his sister noticed swelling over his right foot
which was insidious in onset, gradually
progressive. After about a week it appeared
on entire right leg and thigh and after about a
month it appeared on left leg upto knee and
then later involving abdomen.
• Limb swelling was not a/w postural variation
• Not a/w diurnal variation
• Not a/w periorbital edema, frothy urine ;
decreased urine output
• No history s/o hypothyroidism
• No h/o drug intake
• No h/o chest pain, palpitations
• No h/o difficulty in breathing on lying down
• No h/o upper GI bleed (hematemesis)
• No h/o black tarry sticky stools
• No h/o altered sensorium
But pt has developed yellowish discolouration
in eyes recently
• Pt complaints of abdominal distension since 4
months. It was insidious in onset, gradually
progressive in nature ; initially involving flank
region then umbilicus and later involving the
entire abdomen.
• It was a/w abdominal pain since 3 days which
was generalized dull aching in character,
insidious in onset, present over the entire
abdomen, non radiating, non referred,
aggravated on coughing and bearable by the
pt.
• Pt gives history of usage of 3 pillows under his
back because he has difficulty in breathing on
lying down.
• a/w non documented fever, not a/w chills and
rigor, relieved on taking medications nature of
which is not known by the pt.
• a/w swelling at umbilicus since 4 months,
insidious in onset, gradual in progression,
increased on coughing, reducible manually.
• H/o yellowish discolouration of eyes and urine
since 3 days
• .H/o tattooing in childhood
• H/o blood transfusion 8 years back
• H/o altered sleep pattern. Pt has disturbed
sleep. He sleeps 2-3 hours at night and has
increased daytime sleepiness

• No h/o itching, clay coloured stools

• No h/o iv drug abuse
• No h/o recent travel
• No h/o long term drug intake
• No h/o photosensitivity, skin rash, recurrent
oral ulcers, joint pain.
• No h/o weight loss
• No h/o bronze pigmentation of skin
• No h/o hematemesis, black tarry sticky stools,
breathlessness, urinary disturbance
• No h/o multiple sexual partners
• No h/o ecchymosis, easy bruisability, purpura
• No h/o altered sensorium, behavioural changes,
personality changes
 PAST HISTORY
• H/o surgery for rt leg fracture 8 years back
• No h/o similar complaints in the past.
• No h/o any prior hospitalisation for any
medical condition.
• No h/o TB, asthma, DM, HTN, COPD, epilepsy
 PERSONAL HISTORY
• Mixed diet.
• Normal bowel bladder habits.
• H/o decrease food intake (4 rotis at a time to 1 roti).
• H/o cigarette smoking x 10 years.
• H/o tobacco chewing since past 10 years
• H/o alcohol intake 1 quarter + 1 beer can everyday for
10 years
• No H/O recent travel, IV drug abuse
 FAMILY HISTORY
• No h/o jaundice in any family member.
• No h/o TB in the family.
• No history of any similar complaints in the
family.
 Summary
My pt 33 year old male with no existing co-
morbidities is a chronic alcoholic and smoker
presented to LHMC emergency with B/L lower
limb swelling, abdominal distension,
abdominal pain, fever, jaundice with altered
sleep pattern. There is history of tattooing in
childhood. No h/o high risk behaviour,
hematemesis, melena.
EXAMINATION
GENERAL PHYSICAL EXAMINATION
• Patient was conscious, cooperative, well oriented to
time, place and person lying comfortably on the bed.
Consent was taken before examination and
examination was done in a well lit room
• BMI= 21.3KG/sq meters
• PR= 86/min taken in RIGHT RADIAL ARTERY, regular
rhythm, good volume, 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.
 HEAD TO TOE EXAMINATION
• HAIR – sparse, coarse, black, non brittle and
not easily pluckable.
• Temporal hollowing present
• EYES – icterus present.
• FACE – buccal fat present, no parotid
enlargement
• No cheilosis
• TONGUE- Normal colour and texture.
• GUMS- no bleeding gums.
• Orodental hygiene - poor
• NECK- no visible swelling, JVP not raised.
• Spider naevi not present.
• GYNAECOMASTIA present
• SKIN is dry and coarse.
• Xerosis at elbows and knuckles.
• NAILS - leuconychia present and texture clubbing
absent.
• Flapping tremor absent. Fine tremors of fingers
present.
• Lymphadenopathy absent.
• B/L asymmetrical edema of lower limbs(R>L)
which is pitting in nature.
 SYSTEMIC EXAMINATION
• Respiratory system
Trachea central.
Bilateral chest symmetrical
Bilateral vrsicular breath sounds heard
• CVS- S1 S2 heard, no murmurs, Apex beat
present in 5th intercostal space.
• CNS- Higher mental functions intact.
 PER ABDOMEN EXAMINATION
• INSPECTION-
• Abdomen appears diffusely distended, flanks are full
• Skin appears to be stretched and shiny.
• All quadrants moving well with respiration.
• No visible peristalsis, pulsations.
• Umbilicus is shifted downwards
• Umbilical hernia present. Cough impulse present. Non
reducible on lying down.
• Visible veins are present at right hypochondrium region
• No scar, sinus, fistula
 PALPATION
. Abdomen is afebrile to touch
.Abdomen is normal in consistency.
• Non tender.
• Fluid Thrill present.
• No pulsation/peristalsis
• Abdominal Girth-
- Above umbilicus= 90 cm
-At umbilicus= 92 cm
-Below umbilicus= 87 cm
-right and left spinoumbilical length are equal
.Liver and spleen were not palpable
.flanks are full
.direction of filling of blood in veins is below
upwards
• No other abdominal mass palpable.
 PERCUSSION

•Liver dullness started at 5th intercostal space,

•Lower border could not be appreciated.
• Shifting dullness present.
AUSCULTATION
•Normal bowel sounds heard(2-3 sounds/min).
 DIAGNOSIS

My patient a 33 year old male is provisionally

diagnoed to have chronic liver disease with
decompensated cirrhosis probably of
alcoholic etiology with hepatic
encephalopathy ( grade 1) andfor
spontaneous bacterial peritonitis.
D/D POINTS IN FAVOUR POINTS AGAINST

Alcoholic LIVER History -jaundice 1. HISTORY- edema

DISEASE WITH Ascitis started on feet first
DECOMPENSATED then appeared on
CIRRHOSIS. Cirrhogenice dose abdomen
of alcohol 2. EXAMINATION-
Examination-icteric tinge parotid enlargememt
in eyes absent
Temporal hollowing
Gynaecomastia

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

with decompensated Blood transfusion abuse, multiple sexual
cirrhosis sue to viral 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. Abdominal TB Fever, abdominal pain No history of evening rise

Loss of appetite of temperature, weight
loss, night sweats
 Investigations
• CBC with ESR
• LFT ,KFT, PT-INR
• USG adomen
• Ascitic tap(SAAG)
• Chest x ray
 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. SFurosemide 20 mg BD
- Tab. Spironolactone 50 mg OD

Antibiotics- Tab. Augmentin 625 mg TDS

Tab. Pyridoxine 40 mg
THANK YOU