48yr old male with abdominal distenestion

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A 48 year old male came to OPD with chief complaints of abdominal distension from past 20days.

 HOPI:-

Patient was apparently asymptomatic 20 days back then he developed abdominal distension which was insidious in onset and gradually progressed to present size and not associated with abdominal pain.

10 days back , he went to a local hospital where was given medication, but didn’t give him relief.

H/o SOB ( grade 1 to 2 ) according to mMRC since 20 days, gradually progressive from grade 1 to grade 2 . It increased on exertion and relieved on taking rest.

H/o increased frequency of stools on 15th and 16th April, hard in consistency, green in colour, 5 episodes per day, blood stained and had 5 to 6 drops of blood at the end of defecation. It is not associated with pain and relieved on medication.

H/o bilateral pedal edema since 15 days which is pitting type and extending till the knee joint.

He has decreased urine output since 10 days.

No history of burning micturition.

No H/o orthopnea , PND

No H/o fever, nausea, vomiting

No H/o chest pain, giddiness, cough.

PAST HISTORY:- 

History of jaundice in the past- 2 years back and 6 months back and was managed conservatively with medication.

K/c/o Hypertension since 10 years, initially was on T.TELMA 80 mg which was later reduced to T.TELMA 40 mg and now the patient is on T.amlong 5mg and atenolol 50mg.

N/k/c/o DM-2, TB, asthma, epilepsy,CAD, CVD.

PERSONAL HISTORY:- 

Mixed diet

Alcoholic since 18years

Non smoker

Regular bowel and bladder habits

Reduced appetite since 20days

FAMILY HISTORY:- 

Mother is a known case of HTN,No other relevant family history 

Currently he is staying with his wife, mother ,son and daughter in law

Drug history:Using Tab Telmisartan 40mg,Used tab dytor and UDCA 2years ago.

ON EXAMINATION 

GENERAL Examination:

Patient is conscious, coherent and cooperative

Well oriented to time , place and person.

Moderately built and moderately nourished.

Vitals at presentation:

PR-82bpm

BP-130/80mmhg

RR-22cpm

TEMP- afebrile

No pallor, icterus ,clubbing, Cyanosis, lymphadenopathy

Pitting type of pedal edema+

Loss of muscle mass in extremities+

SYSTEMIC EXAMINATION:

1) PER ABDOMEN:

INSPECTION:

Shape of abdomen:Distended

Umbilicus:inverted

Skin over the abdomen is shiny

All quadrants are moving equally with respiration

No visible peristalsis, Hernial orifices intact

Visible superficial abdominal vein running vertically down is seen

External genitalia normal

PALPATION:

Temperature:Not raised

Tenderness:Absent

No Rebound tenderness 

No guarding rigidity

No hepatosplenomegaly 

Abdominal girth: 104 cms

Direction of flow in left lateral abdominal vein is downwards

Shifting dullness +

No fluid thrill

AUSCULTATION:

Bowel sounds+

No arterial bruit. 

2) CARDIOVASCULAR:

Inspection: precordium normal,apex beat :5th ICS half inch medial to mid

clavicular line

Palpation:inspectory findings confirmed, No thrills or parasternal heave

Auscultation: S152+, no murmurs 

3) RESPIRATORY SYSTEM:

INSPECTION:

Shape of chest:Bilaterally symmetrical, Elliptical in shape

No visible chest deformities

No kyphoscoliosis,

Abdomino thoracic respiration, No irregular respiration

No tracheal shift

No dropping of shoulders, Spino scapular distance appears equal on both sides no sinuses scars engorged veins

PALPATION

Inspectory findings confirmed by Palpation

Chest movements - normal

Chest expansion-equal on both sides

Chest circumference at the level of nipple:84cms-on inspiration:87cms

AP diameter:20cms

Transverse diameter :32cms

PERCUSSION:

Resonant note heard over all areas

AUSCULTATION:

 Norma vesicular breath sounds heard

Vocal resonance: normal in all areas

4) CNS:

Higher mental functions :intact

Cranial nerves intact

Motor system:Normal power,tone,Gait

Reflexes:normal

Sensory examination:Normal

No meningeal signs

PROVISIONAL DIAGNOSIS:- 

Decompensated chronic liver disease