CASE PRESENTATION

PRAJNA BHUSHAN
4th YEAR
KODAGU INSTITUTE OF MEDICAL SCIENCES
MADIKERI
Prajna

PARTICULARS
● Name:Mr. XYZ
● Age: 44years
● Gender: Male
● Education: PUC
● Occupation:Librarian
● Address: Somanahalli,Kadur
● Socioeconamic Status:Upper middle (according to modified BG Prasad
classification)
● Date of admission: 7/04/2020
● Date of examination:8/04/2020
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CHIEF COMPLAINTS
● Distension of abdomen since 6 months
● Fatigue since 4 months
● Swelling of both legs since 15 days
● Breathlessness since 15 days
● Yellowish discolouration of eye and dark coloured urine since 1 week
Prajna

HISTORY OF PRESENTING ILLNESS

● The patient was apparently normal 6 months ago. Then he noticed distension of
abdomen which was insidious in onset and gradually progressive. He had
consulted a doctor at hassan 5 months ago where he was admitted for a week .
He improved symptomatically and is on regular medication since then, details of
which are not known. However after one month of treatment he started
deteriorating in the form of gradual distension of abdomen.
● ???
● Fatigue since 4 months which is gradually worsening and for the last three
months he is not attending his duties.
● Swelling of both legs below knee since 15 days. It started at the ankles and
gradually progressed upto knee . More in the evening hours. Not associated with
pain.
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● He complains of breathlessness without wheeze since 15 days, initially he
was breathless while walking uphill, at present he is breathless while walking
about 100 meters. There is no history suggestive of orthopnea , PND,
trepopnea or platypnea.
● He complains of yellowish discolouration of eye and dark yellowish urine
since 1 week. There is decreased frequency of urination since 1 week which
is 2-3 times per day. However there is no history of generalised itching or pale
stools.
● He gives history of marked thinning of extremeties since 6 months.
Prajna

● No history of fever
● No history of pain abdomen
● No history of increased constipation, nausea ,vomiting or diarrhoea
● No history of chest pain, palpitation
● No history of facial puffiness, hematuria
● No history suggestive of hemetemesis, melaena, bleeding PR
● No history of confusion, drowsiness or alteration of sleep rhythm
● No history of any swelling
CR

● Sir, this 44yr old patient was apparently normal 6 months ago, when he
noticed insidious onset of painless abdominal distension, which was
gradually progressive till the date of examination.

● He had marginal improvement in his symptom for few weeks with some
medications given by a doctor, however he had progressive / gradual
distension of abdomen-thereafter ? On stopping his medications.

● Initially he did not have any leg swelling, but for last one month ( 5
months after onset of Abd. Distension) he has developed leg swelling on
both sides ,more in the evening hrs, and is gradually progressing,
without oliguria , haematuria or facial puffiness.
CR
● From the onset of symptoms he had progressive decrease in appetite, easy
fatiguability & progressive thinning of thighs and arms. There was no h/o other
GI symptoms like nausea ,vomiting, hematemesis, diarrhoea, constipation,
melaena or bleeding PR .
● There was No history of fever during the course of his illness.
● He complains of breathlessness without wheeze since 15 days, which is
progressive.
● There is no history suggestive of orthopnoea , PND, trepopnea , platypnea.
chest pain or palpitation.
● He complains of yellowish discolouration of eyes and dark yellowish urine
since 1 week. However there is no history of generalised itching or pale
stools.
● No history of confusion, drowsiness or alteration of his sleep pattern.
Prajna

PAST HISTORY
● No history of jaundice in past
● No history of blood transfusion, tattoing , body piercing or injection drug
abuse
● He is not a known case of dibetes, hypertension or thyroid disorder
● No history of tuberculosis in the past
● No past surgical intervention
DRUG HISTORY
● He is not known to be allergic to any drug
● For the last 5 months he is taking one tablet on empty stomach and another
half- half tablets morning and afternoon and another half-half tablet morning
and evening.
CR

PAST HISTORY
● No history of similar illness in the past or jaundice in past
● No history of blood transfusion, tattooing , body piercing or injection drug
abuse
● He is not a known case of diabetes, hypertension or thyroid disorder
● No history of tuberculosis in the past
● No past surgical intervention
DRUG HISTORY
● He is not known to be allergic to any drug
● For the last 5 months he is taking some tablets- details are not available /
known to him…… tablet relieves his abdominal discomfort / tablets cause
increased urine …..
Prajna

FAMILY HISTORY
● No similar complaints in the family
Prajna

PERSONAL HISTORY
● Consumes mixed diet
● Normal appetite
● Decreased urination since 1 week
● Regular bowel habits
● sleep is adequate
● He is a chronic alcoholic since 15 years stopped since 3 months -cosumes
360ml of whisky per day = 144g/day
● He is a chronic smoker since 15 years stopped since 3 months- smokes 1
bundle of beedi per day = 15 pack years
Prajna

SUMMARY
A 44 year old gentleman Mr.XYZ
● who is a chronic alcoholic and smoker since 15 years
● with history of distension of abdomen since 6 months for which he is on
medication with partial relief in the first 1 month but later worsening of
symptoms inspite of treatment.
● Fatigue since 4 months
● pedal oedema and breathlessness since 15 days
● Jaundice since 1 week

Based on history it might be a case of massive ASCITES

Prajna

THE CAUSE MAY BE

● Considering the alcoholic history , ascites followed by pedal oedema and
jaundice it might be a case of Cirrhosis of liver with portal hypertension.
● Due to marked thinning of extremeties since 6 months Malignant ascites can
be considered.
● As Tuberculosis is a very common disease in our country , Tubercular ascites
is a probability.
DIFFERENTIAL DIAGNOSIS
● Anaemia with hypoprotenemia
CR
Summary
● Sir my patient is a 44 year old, chronic heavy alcoholic & smoker, presented with
gradually progressive painless abdominal distension and recent leg oedema &
yellow eyes. He has easy fatiguability and progressive thinning of limbs. But he
does not has oliguria, haematuria, or any symptoms of GI bleed.
● He is non hypertensive, nondiabetic and not known to have any cardiac disease.
● I consider him to be having ASCITES.

○ Most likely due to decompensated chronic parenchymal liver disease

( cirrhosis) due to alcohol induced liver disease.

○ I am not sure of portal HTn as he does not give h/o G/I bleed. (?HE)

○ Renal Ascites as in NS , AGN, ESRD are unlikely due to lack of……

○ Cardiac ascites is unlikely due to …….

CR

Other D/Ds
● Chronic Budd-Chiari syndrome

● Malignant ascites
○ Favouring’
○ Against

● Tubercular ascites

● Cardiac ascites

● Hypoproteinaemia ascites
Prajna

PHYSICAL EXAMINATION
A 44 year gentleman, who is moderately built and poorly nourished, conscious, co-
operative and well oriented to time, place and person
VITALS
● Pulse- 64 beats/min, regular, good volume, normal character
● Blood Pressure- 110/70 mmHg, measured in right arm in supine position
● Respiratory rate- 30 cycles/min, Thoracoabdominal
● He is afebrile at the time of examination
● Weight- 52.2kg
● Height- 163 cm
● BMI- 19.64kg/m2
Prajna
HEAD TO TOE EXAMINATION
● Hair- sparse
● Icterus - present
● Pallor is present but no koilonychia, angular stomatitis, purpura or sternal
tenderness.
● 2 spider naevi are present on the chest
● uniform distension of abdomen
● Distended veins over lateral aspect of abdomen
● Umbilical hernia is present . Other hernial orifices are normal
● Bilateral pitting pedal edema -Grade 2
● No- Parotid swelling, palmar erythema, leukonychia, Duperytren’s
contracture, testicular atrophy, gynaecomastia or flapping tremors
● No lymphadenopathy, clubbing or cyanosis
CR
● GPE
● Pallor is present but no koilonychia, angular stomatitis, purpura or sternal tenderness.
● He is Icteric but no scratch marks over trunk.
● He has some more features of CLD like
● sparse hair,
● 2 spider naevii
● Bilateral pitting pedal oedema ,
● but no elevated JVP
● Distended veins on abdomen
● But No- Parotid swelling,
● palmar erythema, leukonychia,
● Duperytren’s contracture,
● Testicular atrophy, gynaecomastia or flapping tremors
● No lymphadenopathy, clubbing or cyanosis
Prajna

INSPECTION.
● There is generalised distension of abdomen, flanks appear full
● Skin is glossy
● Umbilical hernia is present, other hernial orifices are normal
● Superficial veins are visible and dilated on lateral aspects
● All regions move equally with respiration
● No visible scars,sinuses, pulsation or peristalisis

● NEED TO MENTION- ORAL CAVITY, EXAMINATION of ABODOMEN

Prajna

PALPATION
● Done in supine position with both limbs flexed and hands by side of the body
● No tenderness or local rise of temperature
● Divarication of recti present
● Umbilical hernia is present, reducible
● Distended veins in both the flanks and flow from below upwards, no features
of caput medussae
● Spleen is palpable 2cm below left costal margin by dipping method, non
tender, notch felt.
● PR examination not done
Prajna

MEASUREMENTS
● Abdominal girth- 84 cm
● Xiphisternum to pubic symphysis- 42 cm
● Xiphisternum to umbilicus- 24 cm
● Umbilicus to pubic symphysis- 18 cm
● Right ASIS to umbilicus- 18 cm
● Left ASIS to umbilicus- 18 cm
CR
Palpation of the abdomen

● Done in supine position with both lower limbs flexed and hands by side of the body
● No tenderness or local rise of temperature in any quardrents
● Divarication of recti present
● Umbilical hernia is present, reducible
● On standing Distended veins are noted in both the flanks with normal flow pattern.
● Abdominal girth- 84 cm ,
● Xiphisternum to pubic symphysis- 42 cm , Xiphisternum to umbilicus- 24 cm &
Umbilicus to pubic symphysis- 18 cm
● Right & Left ASIS to umbilicus- 18 cm each
● Liver could not be palpable
● Spleen is palpable 2cm below left costal margin by dipping method, non tender.
● No other palpable mass
● Hernial orifices are normal on both sides, and no cough impulse.
● Renal angle is non tender
● PR & testicular examination not done
CR
Prajna

PERCUSSION
● Liver dullness- upper border of liver dullness in 5th intercostal space in mid -
clavicular line, lower border could not be appreciated
● Splenic dullness - upper border is 8cm above the left anterior costal margin in
mid-axillary line.
● Shifting dullness- present
● Fluid thrill - present
CR Percuss- Liver SPAN

Percussion from areas of resonance  dullness.

Note the points - change of resonance.
The distance between the two dullness point is LIVER SPAN.
CR

Nixons
CR
Spleen- percussion
CASTELLs
CR
Prajna

AUSCULTATION
● Normal bowel sounds are heard
● No venous hum over upper abdomen, Friction rub or bruit
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SYSTEMIC EXAMINATION
● RESPIRATORY SYSTEM - Normal vesicular breath sounds heard bilaterally,
no added sounds
● CARDIOVASCULAR SYSTEM- S1 and S2 heard normally, no murmurs
● CENTRAL NERVOUS SYSTEM - Higher mental functions are normal, no
flapping tremors
No neuro defecits
● GENITOURINARY SYSTEM- Normal
Prajna

PROVISIONAL DIAGNOSIS
A 44year old gentleman Mr.XYZ, who is chronic alcoholic and smoker since 15 years with history of
distension of abdomen since 6 months for which he is on medication with partial relief in the first 2
months but later worsening of symptoms inspite of treatment.Fatigue and thinning of extremeties since 4
months. Pedal oedema and breathlessness since 15 days and Jaundice since one week.
On examination
Presence of
● Full flanks
● Uniform distension of abdomen and distended veins in the flanks
● Umbilical hernia and divarication of recti
● Icterus
● Shifting dullness
● Fluid thrill
● Splenomegaly
BASED ON THESE FINDINGS IT MAY BE A CASE OF ASCITES
Prajna

● ASCITES-
Points in favour
● Based on history - Gradual distension of abdomen since 6 months
● Based on examination-
1. Flanks are full
2. Shifting dullness is present
3. Fluid thrill is present
Points against- nil
● Cause may be
1. Cirrhosis of liver with portal hypertension
● Points in favour
* Chronic alcoholic since 15 years
*Presence of jaundice
*Presence of spider naevi
*Splenomegaly
● Points against- Normal appetite
Prajna

Causes for rapid worsening in last two weeks

● Progression of the disease
● Other causes to be considered are
*Subacute Bacterial Peritonitis
*Diuretic over dosage
*Intercurrent infection
*Upper GI bleed
But history and examination findings do not favour any of the above
precipitating factors
Prajna
2. Malignant Ascites
● Points in favour
*Marked thinning of extremeties
● Points against
* No mass , bruit or palpable lymph node
*6 months history
*Absence of fever

3. Tuberculos Ascites
● Points in favour
*Thinning of extremeties
● Points against
*Absence of fever
CR

● Ascites with Jaundice: ● Ascites with abdominal pain

○ Cirrhosis (mild Jaundice) ○ Cirrhosis + SBP

○ Cirrhosis + alcoholic hepatitis ○ Tubercular peritonitis

○ Cirrhosis + HCC ○ Pancreatic ascites

○ Budd- Chiari ○ Peritoneal carcinomatosis

○ Biliary obstruction ( severe ○ Cirrhosis + HCC

jaundice, scratch..)
○ Acute Budd- Chiari
○ Cirrhosis + CHF
○ Cirrhosis + CHF
Prajna

INVESTIGATIONS
● Routine blood investigations-CBC,Prothrombin time, Blood grouping,BT,CT ,
● Stool for occult blood
● Liver function tests
● USG abdomen
● Examination of ascitic fluid- physical, biochemical, cytological and
bacteriological study
● Endoscopy of upper GI tract
● Liver biopsy
CR

Ascitic fluid analysis – technique of paracentesis

● Appearance of ascitic fluid- ? Clear / Cloudy- purulent / red or hemorrhagic /

milky / Straw …

● SAAG = Sr Albumin- Ascitic Albumin

● SAAG >1.1g/dl = ascites due to Portal HT ( High gradient)

○ Cirrhosis, CHF, Chr Budd-Chiari, PV thrombosis, Veno-occlusive

disease…

● SAAG<1.1g/dl = ascites NOT due to Portal HT(low gradient)

○ Tubercular ascites, Peritoneal carcinomatosis, Nephrotic syndrome,

Pancreatic ascites….
CR

Ascitic fluid HIGH SAAG LOW SAAG

>1.1 g/dl <1.1g/dl

HIGH PROTEIN
Cardiac ascites , Tubercular ascites,
Ascitic fluid PROTEIN> 3 gm Myxedema, Peritoneal carcinomatosis
Acute Budd-Chiari.

LOW PROTEIN
CIRRHOSIS NEPHROTIC
<3G
SYNDROME
Prajna

TREATMENT
● Beta blockers
● Diuretics
● Proton pump inhibitors / H2 receptor blockers
● Hepatoprotective drugs???
● Paracentesis
● Transjugular intrahepatic portosystemic stent shunting(TIPSS)
● Liver transplantation

● Abstinence from alcohol / drugs

● DIET
CR

Causes of Splenomegaly
Mild/ Moderate / Massive
Tender spleen

Hepato- Splenomegaly
Splenic rub & bruit

? Differentiate Spleenomegaly /
nephromegaly
CR

? Ascites
? Types
? Exudate v/s Transudate
? Causes
? SAAG
High Protein , High SAAG?
Low Protein , High SAAG ?
Low Protein, Low SAAG?
High Protein, Low SAAG?
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? SBP
? Monomicrobial non- nutrocytic ascites ?
? Poly microbial non- nutrocytic ascites ?
Culture negative Nutrocytic asites?
? Refractory Ascites
? Recidivent ascites
CR

? NCPF
? HE
Rx of UGI bleed
Complications of HBV / HCV
Diagnosis of HBV /HCV
Prevention of HBV /HCV
Rx of HE
Compensated v/s decompensated CLD
Vaccines
Rx of cirrhotic ascites