SHORT CASE

 A 47 year male patient  came with chief complaints of abdominal distension and swelling of bilateral lower limbs since 6 months which is gradually increasing since 10 days and  and fever since 2 days.

History of present illness

Patient was apparently asymptomatic 18 months back then he noticed abdominal distension which is insidious in onset and gradually progressive in nature and subsequently noticed bilateral swelling of lower limbs , he was hospitalized for one week and took medication which increased his urine output and abdominal paracentesis was done and felt better ,, However he discontinued medicine 6 months back and presented with similar complaints where he was hospitalized and treated conservatively , he was hospitalized 3 months back again with similar complaints , again abdominal paracentesis of 1.5 to 2 lit was done. He is on medication , the past 10 days he noticed abdominal distension associated  with swelling of bilateral lower limbs which started at ankle and progressed upto knee 

H/0 of fever, low grade,intermittent in nature not associated with chills, since 2 days,

H/0 of anorexia, fatigue and generalized weakness since 3 months,,

H/0 of disturbed sleep since one month, where he complained of excessive day time sleepiness and night distured sleep,

H/0 of yellowish discoloration of eyes 3 months back now it subsided, 

No h/0 of nausea and vomitings,

No h/0 of pain abdomen

No h/0 of decreased urine output

No h/0 of high coloured urine and clay coloured stools.

No history of shortness of breath

No history of blood transfusions 

Past medical illness- 

 History of abdominal distension , swelling of bilateral pedal oedema, and hematemesis one episode 50 ml 18 months back ,where he admitted in an hospital for 10 days which relieved with diuretics , abdominal paracentesis and gastric oesophageal ligation was done.

Appendicectomy 25 years ago

No history of hypertension, diabetes, thyroid , epilepsy or seizure disorder.

Personal history- 

Diet - mixed

Sleep - disturbed , excessive day time sleep , night time disturbed sleep since one month. 

Appetite- decreased.

Bladder habits- regular and normal.

Habits- chronic consumption of alcohol since 20 years daily , country liquor of 500 ml nearly 110gm per day, and whisky of 150 ml per day nearly 50gm per day, 

Last binge of alcohol - 3 days before admission he took 100gm.

Summary - Decompensated chronic liver disease secondary to ethanol consumption, with ascites, portal hypertension, hepatic encephalopathy stage 1 and spontaneous bacterial peritonitis.

General examination - 

Moderately built and nourished.

Patient is oriented to time , place and person.

GCS - E4 V5 M6  

VITALS - 

Pulse - 82 beats per minute, regular normal volume ,and character, no radio radial or radio femoral delay.

Blood pressure - 100/70 mm Hg, right arm supine position.

Respiratory rate - 18 cpm, thoracoabdominal. 

Spo2- 98 % on room air

Jvp - not elevated.

Physical examination- 

pallor - present

Icterus - absent

No cyanosis

No clubbing

No generalized lymphadenopathy

Pedal edema + 

Head to toe examination- 

Axillary and public hair - sparse.

B/ l parotid enlargement - negative

No fetor hepaticus

No asterixis

No gynaecomastia

Spider nevi - absent

No planar erythema

No leuconchyia

                   

 

                                                                     

                                                                      

                                                   

Inspection - 

Oral cavity - No dental caries and no Tobacco staining

Abdomen - flanks full, distension.

Appendicectomy scar present.

Distened veins present.

No visible peristalsis or no visible pulsations.

Palpation - 

Done in supine position with Both Limbs flexed and hands by side of body.

No tenderness or local rise of temperature.

Abdomen - soft.

No gaurding and rigidity

Hepatomegaly present

Spleen not palpable 

Kidneys bimanually palpable , ballotable.

Fluid thrill - present

Abdominal girth - 98 cms . 

Xiphisternum to umbilicus - 16 cms

Public symphysis to umbilicus - 13cms

Percussion - 

Liver span - 15.7 cm in mid-clavicular line

Auscultation : 

Normal bowel sounds heard.

No hepatic bruit , venous hum or friction rub.

Examination of external genitilia - No testicular atrophy.

Examination of spine - Normal.

Provisional diagnosis - 

Decompensated chronic liver disease

Etiology - chronic ethanol related.

 Ascites , Hepatic encephalopathy grade 1

Esophageal gastric ligation bands were. 

 

Child-Pugh SCORE - C

MELD SCORE - 9

Investigations-

CBP - 

HB - 7.3

TLC - 9600

PLT - 1.97 LAKH

CUE -  

Albumin- trace

Sugar- nil

Rbcs- nil

Pus cells - 2 to 3

RFT -

Blood urea - 12mg/ dl

Serum creatinine - 0.7mg/dl

Sodium - 139 meq/l

Potassium - 3.4meq/l

Chloride - 99 meq/l

Uric acid - 5.0 

Calcium - 9.1

Phosphorus - 7.0 

LFT - 

Total bilirubin - 10.46 mg/ dl

Direct bilirubin - 8.84mg/dl

SGOT - 140IU/L

SGPT - 17 IU/L

ALP - 321 IU/L

Total protein - 6.9gm/dl

Albumin - 2.2 gm/ dl

RBS- 70mg/dl

Ascitic fluid analysis -

SAAG - 1.85. Serumalbumin - 2.2

                         Ascitic albumin - 0.35

Ascitic LDH - 38 IU/ L

Ascitic sugar - 126mg/ dl

Ascitic protein - 0.8 g/dl

Appearance - Clear

Neutrophil count - .

Total count -

RBCS - nil

PT - 18 Sec.

APTT - 35sec.

INR - 1.33

BGT AB+

Hiv - negative.

Hbsag -negative.

Hcv - negative 

                                               CHEST X-RAY AP VIEW

         

ECG