A case of ABDOMINAL DISTENSION.

 

A 48yr old male auto driver by occupation resident of chityala came to our old with chief complaints of:

CHIEF COMPLAINTS:

Abdominal distension since 20 days

Shortness of breathe since 20 days

Reduced urinary output since 20days

Blood in stools since 3 days.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 20 days back he then developed abdominal distension which was insidious in onset and gradually progressed to present size and is associated with loss of appetite since 20 days and yellowish discoloration of eyes.

Abdominal distension is not associated with pain, constipation,nausea, vomiting, weight loss,fever.

Shortness of breathe since 20 days which was inscidious in onset, initially noticed during climbing stairs (MMRC GRADE 2), gradually progressed to dyspnea after walking for smaller distances like 100m(MMRC GRADE 3),associated with bilateral pedal edema.

SOB not associated with chest pain,cough,orthopnea, platypnea,PND.

NO symptoms of lightheadedness,palpitations,lethargy or generalized weakness.

Patient complaints of reduced urinary output since 20 days-1 to 2 episodes per day,slight reddish colored urine not associated with burning micturition and pain during micturition.

Blood in stools since 3 days, bright red colored, noticed on wiping  after passing of stools, stools were green colored solid consistency, no mucus.

PAST HISTORY:

4 yrs back he was diagnosed with alcoholic liver disease when he complained of loss of appetite and weight loss. 

. He took treatment for deaddiction and controlled alcohol intake for 2 years.

He started drinking 2 yrs back and developed  complaint of hemetemesis and jaundice 1 yr back and  was treated conservatively.

HYPERTENSIVE SINCE 10 yrs.presently on amlodipine and atenolol.

No h/o diabetes,TB,ASTHMA,EPILEPSY.

PERSONAL HISTORY:.

Loss of appetite since 20 days

 Sleep is adequate '

Reduced urinary output since 20 days

Blood in stools since 3 days , increased frequency of stools since 2 days(4 to 5 times per day).

Chronic alcoholic since 15 yrs   250 to 500 ml whiskey per day usually at night time, last intake on April 1st.

GENERAL EXAMINATION:

Pallor is absent 

Jaundice is present, dark yellowish discoloration noted on bulbar conjunctiva 

Cyanosis, clubbing are absent

No lymphadenopathy 

Bilateral pitting type of pedal edema noted extending till the knee.

Vitals: 

Pulse 80 beats per minute 

Blood pressure 127/85

Respiratory rate 18 per minute 

Temperature 100.4F 

ABDOMINAL EXAMINATION:

Spider nevi noted on the sides of abdomen.

Palmar erythema noted

Dilated veins noted above the abdomen with direction of flow away from the abdomen.

No signs of alopecia,fetor heapticus,glossitis,oral ulcers,facial puffiness,parotid swelling,Caput Medusae,leuconychia,astrexis,testicular atrophy,gynecomastia.

INSPECTION:

shaped of the abdomen distended

Flanks are full

Spider nevi are present

Umbilicus is flat

No stretch marks

Dilated veins above the umbilicus with direction of flow away from the umbilicus.

PALPATION:

No local rise of temperature 

No tenderness

Liver and spleen are not palpable.

Percussion:

Liver spam 6 cm

Shifting dullness present

Fluid thrill present

Auscultopercussion heard.

AUSCULTATION:

Bowel sounds 5 per minute 

Succussion splash heard.

CARDIOVASCULAR SYSTEM:

 Radial Pulse is 80 beats per minute,regular rhythm,normal volume and radial artery cannot be palpated after occlusion.

INSPECTION:

No epigastric bulge,apical bulge.

Carotid and jugular pulse are visible on lying down and sitting.

PALPATION:

apical impulse felt on 5th ics below the nipple,around 2 to 3 cm.

AUSCULTATION:

S1 is lowder in mitral area and tricuspid area.

S2 is lowder in aortic and pulmonary areas.

No murmurs heard.

RESPIRATORY SYSTEM:

Inspection:

Trachea appears central

Abdomino thoracic respiration 

Shape of chest Elliptical 

Moves symmetrical with respiration

No drooping of shoulders

PALPATION:

Central trachea 

Symmetrical movement with respiration 

TACTILE VOCAL FREMITUS- normal

AP diameter 20cm

Transverse diameter 32cm

AP : Transverse=0.6.

PERCUSSION: 

resonant note in all areas.

AUSCULTATION:

Normal vesicular breath sounds heard

Vocal resonance is normal.

 

USG ABDOMEN:

Spleen 15cms-spleenomegaly

Liver borders were irregular

Gross ascitis.

RECTAL EXAMINATION:

Dilated veins are present 

Skin tag at 4’0 position

Fissure at 6’0 position 

Therapeutic ascitic  tap done on day 2 of admission

Straw colored 

750 ml was drawn .

Lymphotyces 100

Protein 1.2g/dL

Sugars 123mg/dl

No red blood cells noted.

CALCULATION OF SAAG:

ECG

Heart failure with preserved ejection fraction is ruled out buy calculating H2FPEF score.

DIAGNOSIS:

ASCITIS SECONDARY TO CIRRHOSIS AND PORTAL HYPERTENSION 

RECTAL VARICES AND ESOPHAGEAL VARICES SEC TO PORTAL HTN

HEPATO RENAL SYNDROME.

Heart  failure sec to HTN.