A 65 YR OLD MALE WITH ABDOMEN DISTENSION

Case History and Clinical Findings

PRESENTING COMPLAINTS:C/O Abdominal distension and B/L Lower limb swelling since 1 1/2

month.C/O Breathlessness since a month.

HOPI:A 65 year male, a potato chip vendor, resident of Bhongiri, was bought to causality with

complaints of abdominal distension since 1 1/2 month, gradually progressive, not associated with

pain. History of Bilateral lower limb swelling since 1 1/2 month, insidious onset gradually progressive,

pitting type of grade 2. History of breathlessness of grade II to III MMRC, since a month, insidious

onset, gradually progressive, no seasonal or diurnal variation. No history of chest pain, decreased

urine output, PND, Orthopnea, fever, cold, cough. Now admitted for further management and

treatment.

PAST ILLNESS:History of head injury to occipital region which was self healed, pt had altered

behaviour for 6 months.History of CVA - Monoplegia (right upper limb associated with deviation of

mouth to left 15 years ago; used anti coagulants for 5 years and stopped.K/C/O HTN since 6 years,

on TAB. AMLODIPINE 5mg/PO/OD at 8 AMK/C/O T2DM since 6 years on TAB. GLIMEPIRIDE 2mg+

METFORMIN 1000mg/PO/OD at 8 AM.PERSONAL HISTORY:

Decreased appetiteRegular bowel and bladderNo allergiesAlcoholic since the age of 17, takes 160

ML BRANDY till 22 nd sep from 1 st October 90 ml once in 4 days.Smoker since age of 17, initially 36

beedi for a day till 1 st October now 1 beedi per day.

COURSE IN THE HOSPITAL:

A 65 year male clinically presented with above mentioned complaints. Upon admission after initial

examination necessary investigations were done. after explaining the condition and further workup to

the patient and his attendees, diagnostic abdominal paracentesis was done, which showed thick

straw coloured fluid followed by therapeutic paracentesis was done and sent for analysis. Ascitic fluid:

LDH 141 IU/L; Amylase 151 IU/L; Sugar 124 mg/dl; Protein 0.2 mg/dl; Serum Albumin 2.5 mg/dl;

Ascitic Albumin 0.11 mg/dl; SAAG 2.49. His serum osmolality 266 mOsm/kg; Spot urinary: Na+ 142

mmol/l; K+ 151 mmol/l; Cl- 176 mmol/l . Hb 10.5 gr/dl; PCV 32.2; TLC 6100 cellsmm3; Platelet count

1.5 lakhs/mm3.

He was started on IV Antibiotics, Loop diuretics, Oral Rifiximine, Pottasium supplements and other

Liver supportive medications.

USG Abdomen was domne on 13/12/2022 which showed:

1. Liver : 12.8 cms , normal size and coarse echotexture, No IHBRD, Gall bladder wall edema (5mm),

Portal vein 11mm showing hepatopetal and biphasic pattern.

2. Spleen 2.6 cms with normla size and echotexture,

3. Right kidney of 9.6 * 5.4 cms and Left Kidney 9.3 * 5.2 cms with normal size and echotexture, CMD

maibntained and

2d echo findings

no rwma

mild TR + ,TRIVIAL MR+

DIASTOLIC DYSFUNCTION + NO PE

EF 60% MILD AS AND AR POSITIVE

IVC SIZE 1 CMS COLLAPSING

AT PRESENT HEMOGRAM FINDINGS

HB 9.7

TC 10,300 , N/L/M/E/ 90/03/06/01 PCV 30.5 RBC 3.25 ,PLT 1.20

PT 14 ,INR 1.0 ,APTT 29

PATIENT AND PATIENT ATTENDERS HAVE BEEN EXPLAINED ABOUT THE PATIENT

CONDITION THAT IS ALTERED SENOSRIUM SECONDARY TO HEPATIC ENCEPHALOPATHY,

DIAGNOSED WITH DECOMPENSATED LIVER DISEASE AND VARIOUS COMPLICATIONS THAT

MAY ARISE, INCLUDING THE MORTALITY OF THE PATIENT IN THEIR OWN

UNDERSTANDABLE LANGUAGE BUT THEY DENIED FURTHER HOSPITAL STAY AND

TREATMENT AND UNDER LEAVING AGAINST MEDICAL ADVICE DUE THEIR PERSONAL

REASONS.

HOSPITAL STAFF, DOCTORS ARE NOT RESPONSIBLE FOR ANY DETORIATION OF THE

PATIENT CONDITION

Diagnosis

CHRONIC DECOMPENSATED LIVER DISEASE;

HIGH SAAG LOW PROTEIN ASCITES SECONDARY TO ALCOHOLIC LIVER CIRRHOSIS WITH

GRADE 3 ENCEPHALOPATHY

B/L LOWER LIMB SWELLING (GRADE III);

HYPERVOLUEMIC HYPONATREMIA;

HYPOKALEMIA SECONDARY TO CHRONIC LIVER DISEASE;

K/C/O CVA- MONOPLEGIA (RIGHT UPPERLIMB) WITH DEVIATION OF MOUTH TO LEFT 15

YEARS AGO .

K/C/O DIABETIS MELLITUS 10 YEARS AGO.

K/C/O HTN 10 YEARS AGO.

Treatment Given(Enter only Generic Name)

1 TAB. RIFAGUT 550MG PO BD

2 TAB. ALDACTONE 50MG PO BD

3 TAB.UDILIV 300MG PO BD

4 TAB. HEPAMERZ 500MG PO OD

5 TAB. AMLONG 5MG PO OD

6 TAB.FOLIC ACID 5MG PO OD

7 TAB.BENFOTHIAMINE 100MG PO BD

8 INJ. HYDROCORT 100MG IV BD

9 INJ. HUMAN ACTRAPID INSULIN S/C TID ACCORDING TO GRBS

10 SYP.POTKLOR 15ML/PO/TID IN 1 GLASS OF WATER

11 INJ.MONOCEF 1GM IV BD

12 SYP.LACTULOSE 30ML PO TID

13 GRBS MONITORING 6TH HOURLY

14 NEB.IPRAVENT 8TH HOURLY

Advice at Discharge

PATIENT ATTENDERS HAVE BEEN EXPLAINED ABOUT THE PATEINT CONDITION THAT IS

ALTERED SENSORIUM SECONDARY TO HEPATIC ENCEPHALOPATHY DIAGNOSED WITH

CHRONIC DECOMPENSATED LIVE DISEASE AND VARIOUS COMPLIACTIONS THAT MAY

ARISE INCLUDING MORTALITY OF THE PATIENT IN THEIR OWN UNDERSTANDABLE

LANGUAGE BUT THEY DENIED FURTHER HOSPITAL STAY AND TREATMENT AND ARE

LEAVING AGAINST MEDICAL ADVICE DUE TO THEIR OWN PERSONAL REASONS

HOSPITAL STAFF DOCTORS ARE NOT RESPONSIBLE FOR ANY DETORIATION OF PATIENT

CONDITION

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.