CASE

PRESENTATION
BIODATA
• Rajan
• 63 yrs,male
• Thirur
• manual labourer, stopped for past 3 years

• PRESENTING COMPLAINTS

• abdominal distension-1 month

• Pedal edema-1 month
• Alteration in sleep pattern - 5 days
HISTORY OF PRESENT
ILLNESS
• 63 year old male with previous history of
abdominal distension and vomiting of blood now
presented with insidious onset of abdominal
distension for past one month
• Generalised distension,progressive over days
• More distended in last one week
• Associated with difficulty in lying down position
and breathlessness on exertion
• No aggregating and relieving factors
• Bilateral pedal edema for past 1 month
• No diurnal variation of the symptoms
• Bystander also complaints of increased sleepiness
of the patient during day hours and decreased
sleep at night noticed in past 5 days.
• No h/o abdominal pain,vomiting, hemetemesis,passing
of black tarry foul smelling stools,yellowish
discoloration of urine or skin,pruritis,clay coloured stool

• No h/o fever ,loss of appetite,recent intake of alcohol or

drugs,recent change in diet

•
• No h/o any neuropsychiatric disease ,

• No h/o blood transfusion ,injecting drug

use,tattoos,travel history

• No h/o reduced urine output,frothy urine,

hematuria

• No history of cough, hemoptysis

• No h/o chestpain ,syncope, palpitation,orthopnea,,

paroxysmal nocturnal dyspnea.
HISTORY OF PAST ILLNESS
• 1 year back- h/o vomiting blood ,about 1L ,on
reaching hospital had one more episode
• H/o passing black tarry sticky stools for 3 days since
that episode ,foul smelling and difficult to flush out
• No history of abdominal distension ,pedal edema
or jaundice then.
• No h/o iron tablet intake
• In past 6 months having abdominal distension and
pedal edema and frequent visit to hospital and
history of fluid tapping from abdomen
• H/o weight loss in past 5 months

• No h/o diabetes, hypertension, dyslipidemia, tuberculosis,

bronchial asthma,coronary artery disease

• No h/o blood transfusions,fever with jaundice,peptic ulcer disease

• No history of any drug intake,indigenous drug or antituberculous

therapy

• FAMILY HISTORY

• No similar illness in the family

• Brother is diabetic.
• PERSONAL HISTORY
• Mixed diet,normal appetite
• Reduced sleep at night, increased sleepiness
during day
• Normal bowel and bladder habits
• Alcohol consumption for past 25 years and
stopped 6 months before
• No habit of smoking and no other addiction

• SOCIOECONOMIC STATUS
• middle class family
• GENERAL EXAMINATION
• Drowsy and preferred to sleep during examination
• Moderately built and poorly nourished
• Pallor ,icterus,clubbing present
• No cyanosis and lymphadenopathy.
• Bilateral pitting pedal edema present

• HEAD TO FOOT EXAMINATION

• Frontal balding,temporal hollowing
• Loss of axillary hair and body hair
• White nails ,dry skin,
• No flapping tremor,spider naevi,gynecomastia
• VITALS

• Pulse: 64 bpm,regular rhythm,normal volume

and character,no vessel wall thickening, other
peripheral pulses palpable
• BP:100/70mmHg lying down position ,right
upper arm
• Respiratory rate: 18/min ,regular
rhythm,abdominothoracic
• Afebrile
EXAMINATION OF GIT
• EXAMINATION OF UPPER GIT

• lips ,angle of mouth,gums,palate,

tongue,buccal mucosa - normal
• Poor oral hygiene
EXAMINATION OF
ABDOMEN
• INSPECTION
• Abdomen distended, generalised distension
• Flanks full,umbilicus central everted
• Movements of abdominal wall with respiration
present and normal
• No other visible peristalsis or pulsation
• Dilated veins on the surface of abdomen
• No scars,striae,pigmentation of abdominal wall
• No localised bulging ,retraction or impulse on
coughing at hernial orifices
• PALPATION
• no local rise of temperature,tenderness
• Liver Not able to palpate
• Spleen not able to palpable
• No other palpable mass in abdomen
• Abdominal girth 93 cm
PERCUSSION
liver dullness right 5th intercostal space
Liver span 11cm
Traubes space dull
Shifting dullness present
Fluid thrill present

AUSCULTATION
normal bowel sounds
No hepatic bruit
No venous hum ,splenic rub
• EXAMINATION OF CARDIOVASCULAR SYSTEM
• shape of precordium normal
• JVP not elevated
• apex beat not visible ,felt in 5th left intercostal space
in midclavicular line
• First and second heart sound heard
• EXAMINATION OF RESPIRATORY SYSTEM

• Trachea central,movement of chest wall

normal
• Normal vesicular breath sound heard in all
areas bilaterally
• No adventitious sounds
• EXAMINATION OF NERVOUS SYSTEM
• patient drowsy, alteration in sleep
pattern
• Oriented , cooperative
• Normal speech , memory,intelligence
• Sensory and motor system within
normal limits
• Reflexes normal
• Plantar response -bilateral flexor
SUMMARY

• 63 year old male ,with a history of alcohol

consumption for past 25 years and history of
hemetemesis ,recurrent abdominal distension and
fluid tapping for the past 1 year , now presented
with abdominal distension and pedal edema for 1
month and alteration in sleep pattern for past 5
days

• On examination patient was drowsy

• he had few stigmata of chronic liver disease,

• pulse was 64bpm,BP 100/70 mmHg

• On examination of abdomen , generalised

distension,flanks full umbilicus everted, dilated veins
on abdomen ,direction of flow away from abdomen

• Traube's space was dull

• Shifting dullness and fluid thrill prese

DIAGNOSIS
Decompensated chronic liver disease with
features of portal hypertension and hepatic
encephalopathy
Etiology : Alcoholism
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