45 year old male with abdominal distension

This  is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.

A 45 yr old male patient came with chief c/o yellowish discolouration of sclera since 20 days

Abdominal distension since 20 days

Pedal edema since 20 days

SOB since 15 days

HOPI-

Pt was apparently asymptomatic 5 years back then he developed vomitings , went to hospital, where he was told low BP, hypokalemia. Then he recently developed similar complaints associated with jaundice .

20 days back he developed abdominal distension , yellowish discolouration of sclera and urine associated with b/l pitting type of pedal edema up to knee .

No history of chest pain ,hemoptysis, abdominal pain , burning micturition ,increased frequency of micturition or urgency

Past history -

Not a k/c/o HTN,DM,BA,TB

Personal history-

Diet -mixed 

Appetite- normal

Bowel and bladder  movements-regular 

Consumption of 360ml of whiskey per day since 15 years

Chewing of gutka since 10 years 

No known allergies 

General examination 

Pt is conscious, coherent, cooperative 

Weight -53 kgs , height -165cms 

BMI-19.4

B/l pitting type of edema up to knee - present 

Icterus +

No signs of pallor, cyanosis, generalised lymphadenopathy 

Vitals -

Bp-110/70mmhg

PR-92 bpm 

RR-18cpm

Temp - afebrile 

Spo2-91% at RA

GRBS-138 mg/dl 

Systemic Examination

Respiratory-

Dyspnea- present 

Centrally positioned trachea 

Vesicular breath sounds are heard

No added sounds 

P/A- inspection 

Shape of abdomen- distended , with abdominal girth of 85cm

Umbilicus- transverse slit like 

Non tender , visible distended veins , multiple scars over abdomen are present , no visible sinuses

Palpation -Mild hepatosplenomegaly 

Percussion - shifting dullness present 

Auscultation- bowel sounds +

CVS -S1,S2 heard, no murmurs 

CNS -NAD 

Probable Diagnosis : CIRRHOSIS WITH PORTAL HYPERTENSION secondary to ALCOHOL consumption.

Investigation: 

✓CBP, clotting time, bleeding time,hep B and c, Hiv

✓LFT

✓RFT

✓Chest X Ray

✓ US abd

Treatment -Fluid and salt restriction diet

Laxic40 mg bd                                                               

Lactulose 10 ml

Thiamine  

Aloactone25 mg.