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Ultrasound abdomen
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
This is a case of a 65 year old retired gentleman who came to the hospital with chief complaints of Shortness of Breath since 10 days and fever since 10 days and bilateral lower limb swelling since 6 months.
HISTORY OF PRESENTING ILLNESS
The patient was apparently alright 9 months ago. Then in March he developed shortness of breath of grade 3 which was insidious in onset and gradually progressive. Associated with orthopnea. No PND.
He also developed abdominal distension
He was taken to the hospital and ascitic tap was done. His symptoms decreased and he was taken home.
He developed bilateral swelling of the lower limbs since 6 months. The swelling is up to the knees and it initially decreased on rest, but now it remains the same throughout the day.
He also noticed yellowish discolouration of his palms since the past few months.
He had a similar episode of sob and abdominal distension and was taken to the hospital. Ascetic tap was done again.
At present:
He developed sob of grade 2 to 3 since a month which was insidious in onset and gradually progressive. He developed fever since 10 days, associated with chills and evening rise of temperature. It relieves on medication. No association with headache, body pains, nausea vomiting, diarrhoea, burning micturation, rash, decreased urine output.
Past history
Diagnosed with HTN and DM 6 yrs back
He is on medication
1 t amlodipine 5 mg po/od at 8 am
2. T glimipiride 2 mg + met formin 1000 mg po/ od at 8 am
He is known case of CVA hemiplegia on rt side with deviation of mouth to left side 15 yrs ago
Got treatment for 5 yrs -resolved
H/o head injury 30 yrs ago in a train accident pt had injury at occipital region of scalp followed by altered behaviour for 6 months and used treatment for 6 months and resolved
H/o rt knee joint pain 5 yrs back
PERSONAL HISTORY:
Sleep - Decreased from 2 years
Diet - Mixed
Appetite - decreased
Bowel and bladder movements : regular
Addictions : Alcoholic
Started at 17 yrs daily 160 ml brandy till sep 2022 from 1 St oct 90ml
Tobacco
Started at 17 yrs 36 beedis / day till sep 22
Daily 1 beedi / day from 1 St oct
Treatment history
Blood transfusion 5 months ago
Drug history
T etophylline and T theophylline po/hs. Since 5 days
General examination
Pt. is conscious , coherent , cooperative
Vitals
BP 140/90 mmhg
PR 90bpm RR 18
GRBS. 114 spo 2 95
Pallor - absent
Icterus - absent
Cyanosis - absent
Clubbing - present
Lymphadenopathy : absent
Edema : Present till knee level and of pitting type
Per ABDOMINAL examination
INSPECTION
Abdomen is DISTENDED with flanks full
umbilicus is central slit like
Peude orange type of skin
No scars and sinuses
No ENGORGED veins
No visible pulsation
PALPATION :
all inspectory findings confirmed
No rise of temperature and tenderness
No guarding and rigidity
Organomegaly not able to elicit
Abdominal girth was127cms
At present 125 cms at umbilicus
Weight was 100kg
PERCUSSION :
Shifting dullness - Present
Fluid thrills - negative
Puddle sign cannot be elicited ,as pt is not cooperative
:Abdominal girth 127 now 125 at umbilicus
Weight was 100kg
AUSCULTATION :
bowel sounds are heard
No bruits
CVS
S1S2 +, no murmurs
Respiratory system
BAE + with b/l Ronchi
CNS
HMF intact
Power u/ l l/l
Rt. 5/5. 5/5
Lt. 5/5. 5/5
Reflexes.
Rt. Lt
Biceps. ++. ++
Triceps. +. +
Supinat. +. +
Knee. _. Ve. _ Ve
Ankle. _ Ve. _. Ve
Plantar. F. F
No cerebellar and meningial signs
INVESTIGATION S
Gall bladder edema
Liver. Coarse echotextire with irregular surface
So chronic liver disease
No IHBRD
Gross ascites
Diagnosis
CHRONIC DECOMPENSATED LIVER DISEASE WITH HIGH SAAG LOW PROTEIN ASCITES SECONDARY
TO ALCOHOLIC LIVER DISEASE WITH B/L LOWER LIMB EDEMA GRADE 2 WITH HYPONATREMIA AND HYPOKALEMIA
Treatment
1 Inj. Lasix 40mg iv/od
2 T. Aldactone 50mg po/od
3 Syp. Lactulose 15ml po/tid
4 Inj HAI s/c acc. To grbs
5. Tab. Amlong 5mg po/od
6. Fluid restriction < 1.5L/day
7. Salt restriction < 2 g/day
8 Therapeutic paracentesis
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