50 year old man with ascites

 Final case report - Short case

Name - A. Rishi koundinya

Hall ticket number- 1701006010

Batch - 2017

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Chief complaints

50 year old male, farmer by occupation, resident of Pochampally, came to Medicine OPD with complaints of : 

* Distended abdomen since 7 days 

* Pain abdomen since 7 days

* Pedal edema since 5 days 

* Breathlessness since 4 days.

History of presenting illness

The patient was apparently asymptomatic 6 months ago when he developed jaundice and was treated at a private practitioner.

Later he developed abdominal distension about 7 days ago - insidious in onset, gradually progressive to the present size - associated with 

Pain in epigastric and right hypocondrium - colicky type.

Fever - high grade, not associated with chills and rigor, decreased on medication, No night sweats.

Not associated with Nausea, vomiting, loose stools 

There was pedal edema 

Gradually progressive 

Pitting type

Bilateral 

Below knees

Increases during the day - maximum at evening.

No local rise of temperature and tenderness 

Grade 2 

Not relived on rest 

He also complained of shortness of breath since 4 days - MRC grade 4

Insidious in onset

Gradually progressive 

Agrevated on eating and lying down ; No relieving factors

No PND

No cough/sputum/hemoptysis

No chest pain

No wheezing

Patient is a known alcoholic since 20 years. Ascites increased after his last drink on 29th May, 2022. Alcohol- 2 times a week, 180 ml.

Past history

No history of similar complaints in the past 

Medical history- not a known case of DM, HTN, TB, Epilepsy, Asthma, CAD

Surgical history - not significant 

Personal history

Diet - mixed

Appetite- reduced since 7 days

Sleep - disturbed

Bowel - regular

Bladder - oliguria since 2 days, no burning micturition, feeling of incomplete voiding. 

Allergies- none

Addictions - Beedi - 8-10/day since 20 years ; 

    - Alcohol - Toddy - 1 bottle, 2 times a week, since 20 years;

  - Whiskey-180 ml, 2 times a week, since 5 years.

 - Last alcohol intake - 29th May, 2022.

General examination

Patient is conscious, coherent and co-operative.

Examined in a well lit room

Moderately built and nourished

Icterus - present

Pedal edema - present - bilateral pitting type, grade 2              

   No pallor, cyanosis, clubbing, lymphoedenopathy.

    

Vitals : 

Temperature- febrile

Respiratory rate - 16cpm

Pulse rate - 101 bpm

BP - 120/80 mm Hg.

Systemic examination:

CVS : S1 S2 heard, no murmurs

Respiratory system : normal vesicular breath sounds heard.

Abdominal examination

INSPECTION : 

 Shape of abdomen- distended

Umblicus - everted

Movements of abdominal wall - moves with respiration 

Skin is smooth and shiny;

No scars, sinuses, distended veins, striae.

PALPATION : 

Local rise of temperature present.

Tenderness present - epigastrium.

Tense abdomen 

Guarding present

Rigidity absent 

Fluid thrill positive 

Liver not palpable 

Spleen not palpable 

Kidneys not palpable 

Lymph nodes not palpable 

PERCUSSION: 

Liver span : not detectable 

Fluid thrill: felt 

Investigations

Serology: 

HIV - negative 

HCV - negative 

HBsAg - negative 

PROVISIONAL DIAGNOSIS: 

Liver failure with ascites.

TREATMENT: 

Syp. Lactose 15ml TID

Abdominal girth charting - 4th hourly

Fluid restrictriction less than 1L per day

Salt restriction less than 2 gms per day