39 year old male patient from West Bengal

This is a case of a 39 year old bus driver who is a resident of West Bengal.

CHIEF COMPLAINT:
  • Abdominal distension since 2 months.
  • Swelling in the leg since 2 months.
  • Decreased appetite since 2 months.
  • Decreased urine output since 1 month.

 HISTORY OF PRESENT ILLNESS-

Patient was apparently asymptomatic 2 months ago then he developed abdominal distension which was insidious in onset and gradually progressive, associated with decreased appetite. Later he developed bilateral pedal edema extending upto the knees which is of pitting type.
After a month his urine output got decreased still he continued his work as a bus driver.
His relatives started noticing that his abdomen is getting distended and his appetite is decreased.
They suggested him to see a doctor following which he took a homeopathic treatment in West Bengal But there was no improvement. He also took some ayurvedic medication but nothing seemed to work out. Then he came to our hospital with complaints of abdominal distension,pedal edema and decreased appetite.
No history of fever, breathlessness, cough 
No h/o drowsiness, loss of consciousness, palpitations, orthopnoea,pnd ,abdominal pain, fever,nausea vomiting. 

PAST HISTORY:
  • Not a known case of diabetes mellitus, hypertension, tuberculosis, epilepsy or any other chronic illness.
  • No surgical history.

PERSONAL HISTORY:
  •  Married, 2 daughters 
  • Diet :mixed (consumes fish and meat)
  • Appetite: normal ( presently)
  • Sleep: disturbed 
  • Bowel and bladder: normal
  • Addiction : betel, bidi, alcohol 
  • Allergy: none
  • Hobbies: watching telivision  

Daily routine:
  • The patient gets up early morning at 5am. After freshing up he takes water, one cup of  lemon tea with biscuits. Then he rides his cycle almost around 5km to reach his bus stand where he is working as a bus driver. By 6:30 am he starts from Siliguri.
  • Sometimes he takes a 72 hrs shift (West bengal to Assam).
  • Around 9am he stops his bus for having breakfast which mainly includes rice,dal, vegetables or fish. 
  • Next stop he takes around 1pm for lunch ( rice and fish). 
  • His assistant takes up the driving duty from there. At 10pm they finally go for dinner in a restaurant which mainly includes rice ,dal,vegetables or fish.
  • Later he continues driving till next day morning.


FAMILY HISTORY:

Not significant 

Clinical images




General examination:

Patient is conscious ,coherent and cooperative and well oriented to time, place , person.

Patient was examined in a well lit room after taking their consent. 

Patient is undernourished.

  • Pallor- present 
  • Icterus -absent
  • Cyanosis-absent
  • Clubbing-absent
  • Generalised Lymphadenopathy-absent
  • Edema-bilateral pedal edema present

VITALS
  • Temperature : 98.3℉
  • PR : 90 beats per minute
  • BP : 100/70 mm of Hg
  • RR : 22 cycles per minute
  • SpO2 : 96% room air

Systemic examination

Per abdomen:
Inspection- 

  • Abdomen is distended , flanks are full, skin is stretched.
  • No visible peristalsis, scars, sinuses, hermial orifices.
  • Equal symmetrical movements in all quadrant’s with respiration.
  • Umbilicus: central


Palpation - 

  • No local rise of temperature, no tenderness
  • All inspectory findings are confirmed by palpation, no rebound tenderness, gaurding and rigidity.
  • Liver and spleen not palpable.
  • No organomegaly 
  • Fluid thrill present 

Percussion:

  • Shifting dullness present 

Auscultation:

  • Bowel sounds heard 

CVS : 
Jvp not raised 

Inspection:

  • Shape of chest - elliptical
  • No visible pulsations
  • No engorged veins and scars 
  • Apical impulse not visible

Palpation:

  • Apex beat present over the left 5th intercostal space 1cm medial to midclavicular line
  • No parasternal heave
  • No precordial thrill
  • No dilated veins

Auscultation:

S1 S2 heard ,No murmurs 

CNS: 
No focal neurological deficits
Cranial nerves,motor and sensory functions intact. 

RR: 
  • Upper respiratory tarct - normal
  • Lower respiratory tract-
  • Inspection:
  • Chest bilaterally symmetrical,
  • Shape- elliptical
  • Trachea- Midline
  • Palpation:
  • Trachea is Midline
  • Normal chest movements
  • Vocal fremitus is normal in all areas 
  • Normal vesicular breath sounds

No added sounds

shape of the chest: normal

Investigation: 

Chest xray


USG abdomen 


Ascitic fluid


Apraxia charting: 


























PHES test



Interpretation:



Ascitic tap - 

  • Appearance - clear , yellow coloured 
  • SAAG - 1.65 g/dl
  • Serum albumin - 2.0 g/dl
  • Asctic albumin - 0.35 g/dl
  • Ascitic fluid sugar - 104mg/dl
  • Ascitic fluid protein - 0.7 g/dl
  • Ascitic fluid amylase - 17 IU /L
  • LDH : 143 IU/L 
  • Cell count- 50 cells 
  • Lymphocytes nil
  • Neutrophils 100%.

Provisional diagnosis:

Portal hypertension with ascites 

TREATMENT :

Tab LASIX 40 mg PO BD

Syp. Lactulose 10 ml PO HS

Strict Alcohol abstinence .

Comments

Post a Comment

Popular posts from this blog

OSCE and Learning points

Image
OSCE AND LEARNING POINTS PREFINAL PRACTICAL EXAMS NAME : VAGISHA RANI ROLL NO: 138 DATE: 4 December '23 Blog link: https://vagisharani.blogspot.com/2023/12/48-year-old-male-patient-from-west.html QUESTIONS  1) West haven criteria clinical grade for hepatic encephalopathy. 2) Wilson's disease and cirrhosis of liver  Wilsons diease is an inborn errors of copper metabolism characterised by increased total body copper. Etiology: Molecular defect within the copper transporting ATPase encoded by gene ( ATP7B) located on chromosome 13 Pathology:  Copper enters the body through the digestive tract with the help of a transporter protein in the cells of the small bowel, copper membrane transporter 1 (Ctr1; SLC31A1).  In response to rising copper levels, an enzyme called ATP7A releases copper into the portal vein to the liver. Liver cells carry the CMT1 protein and metallothionein, and then ATOX1 binds it inside the cell. Once here, ATP7B links the copper to ceruloplasmin and
Read more

65 year old male

Image
65 year old male from beemanapally Date of admission 21/7/23 65 yr old male agricultural labourer by occupation came to OPD with C/O abdominal pain, lower back pain radiating to b/l lower limbs, neck pain with stiffness since 1 year.  History of present illness:   Patient was apparently asymptomatic 1 year ago later he developed pain in abdomen which Insidious in onset gradually progressive. It is diffuse and dull causing discomfort.It is aggravated on eating,performing daily activities and walking. Pain in the chest is lasts for 2-5 min which is sudden in onset.It is relieved by massaging that particular area. Yesterday night patient complained of pricking type of headache due to dental carries on the right lower molars due to which he was unable to sleep.   Past illness: Diabetes since 15 years. Not a K/C/O  HTN, TB, asthma, epilepsy or any other chronic illness. History of Trauma 4 years back, then he had a fall while taking his cattle to the field due to which the patient experienc
Read more