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20

 Case History and Clinical Findings

A 45 YEARS OLD MALE, CAME WITH COMPLAINTS OF

ABDOMINAL DISTENSION AND SHORTNESS OF BREATH AND SWELLING OF BOTH LOWER

LIMBS SINCE 1 WEEK

HOPI:

PATIENT WAS ASYMPTOMATIC,6 YEARS AGO AND THEN HE DEVELOPED A MINOR INJURY

TO NECK WHICH WAS NOT HEALING AND THEN WENT FOR REGULAR CHECKUP AND WAS

DIAGNOSED AS HAVING DIABETES AND STARTED ON OHA, AND 3 YEARS AGO HE WAS

DIAGNOSED TO BE HAVING HYPERTENSION AND STARTED ON TAB. TELMISARTAN

40MG/OD,AND WAS ASYMPTOMATIC 7 MONTHS AGO AND THEN IN THE EVENING HE

SUDDENLY BECAME ,UNRESPONSIVE AND IRRELEVANT TALK AND WAS TAKEN TO

HOSPITAL AND WAS FOUND TO BE HAVING HYPOGLYCAEMIA AND WAS ASKED TO STOP

OHA,AND WAS FOUND TO BE HAVING JAUNDICE AT THAT TIME AND WAS ASKED TO AVOID

ALCOHOL BUT HE DIDN’T STOPPED ALCOHOL CONSUMPTION.

AND 5 MONTHS AGO,HE DEVELOPED SIMILAR COMPLAINTS AND WAS ADMITTED HERE AND

WAS DIAGNOSED TO BE HAVING,ACUTE DECOMPONSATED LIVER DISEASE AND WAS KEPT

ON CONSERVATIVE MANAGEMENT, A DIAGNOSTIC AND THERAPEUTIC TAP WAS

DONE,SHOWING 200CELLS,LYMPHOCYTIC PREDOMINANT CELLS AND HIGH SAAG AND LOW

PROTEIN PROFILE AND THERAPEUTIC PARACENTESIS WAS DONE 1L ON DAY 1 1.75L ON DAY 2 AND 1.5L ON DAY 3 AND HIS COMPLAINTS RESOLVED AND WAS

DISCHARGED IN A HEMODYNAMICALLY STABLE STATE,AND WAS NORMAL TILL 15 DAYS

AND STARTED DEVELOPING PEDAL EDEMA ,ABDOMINAL DISTENSION AND SOB AGAIN AND

CAME HERE FOR FURTHER MANAGEMENT.

DECREASED APETITE AND SLEEP SINCE 2 DAYS.

CHRONIC ALCOHOLIC SINCE 20 YEARS AND LAST BINGE,30DAYS AGO.

CHRONIC SMOKER SINCE 30YEARS

PAST HISTORY:

K/C/O CLD SINCE 5 MONTHS

K/C/O HTN SINCE 2 YEARS

K/C/O DM II SINCE 6 YEARS

PERSONAL HISTORY:

CHRONIC ALCOHOLIC CONSUMES 3 QUARTERS/DAY

CHRONIC SMOKER 40 CIGARETTES/DAY (SINCE 30 YEARS)

GENERAL PHYSICAL EXAMINATION:

AT ADMISSION

PATIENT IS DROWSY BUT AROUSABLE,

ICTERUS : PRESENT

CLUBBING: PRESENT

PEDAL EDEMA: PITTING TYPE

NO SIGNS OF CYANOSIS, GENERALISED LYMPHADENOPATHY

BP 140/80MMHG

PR 98BPM

RR 18CPM

TEMP AFEBRILE

SPO2 98% ON RA

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

S1 AND S2 HEARD. NO MURMURS

RESPIRATORY SYSTEM: BAE PRESENT. NVBS HEARD

CENTRAL NERVOUS SYSTEM:

PATIENT IS DROWSY AND AROUSABLE

SPEECH NORMAL

NO SIGNS OF MENINGEAL IRRITATION

P/A

DISTENDED,AND

UMBILICUS EVERTED

DILATED VEINS PRESENT OVER THE LOWER ASPECT OF ABDOMEN

AND SHIFTING DULLNESS POSITIVE AND FLUID THRILL NEGATIVE.

ABDOMINAL GIRTH 124CMS

GENITALS EXAMINATION:

SCROTAL SWELLING PRESENT


Advice at Discharge

1. TAB. LASIX 60 MG IV/BD X 7 DAYS 8AM--X--7PM

2. TAB. TAXIM 200 MG PO/BD X 5 DAYS

3. FLUID RESTRICTION <1.5LIT/DAY

4. SALT RESTRICTION <1.2 GM/DAY

5. TAB. RANTAC 150 MG PO/OD/BBF

6. TAB. ALDACTONE 50 MG PO/OD X 7 DAYS X--X--7PM

7. TAB. TELMISARTAN 40 MG PO/OD

8. SYRUP. LACTULOSE 30 ML PO/TID

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