39 year Old Male patient from West Bengal

39 year old male patient from West Bengal 

This is a case of a 39 year old bus driver who is a resident of West Bengal.

CHIEF COMPLAINT:

Abdominal distension since 2 months.

Swelling in the leg since 2 months.

Decreased appetite since 2 months.

Decreased urine output since 1 month. 

HISTORY OF PRESENT ILLNESS-

Patient was apparently asymptomatic 2 months ago then he developed abdominal distension which was insidious in onset and gradually progressive, associated with decreased appetite. Later he developed bilateral pedal edema extending upto the knees which is of pitting type.

After a month his urine output got decreased still he continued his work as a bus driver.

His relatives started noticing that his abdomen is getting distended and his appetite is decreased.

They suggested him to see a doctor following which he took a homeopathic treatment in West Bengal But there was no improvement. He also took some ayurvedic medication but nothing seemed to work out. Then he came to our hospital with complaints of abdominal distension,pedal edema and decreased appetite.

No history of fever, breathlessness, cough 

No h/o drowsiness, loss of consciousness, palpitations, orthopnoea,pnd ,abdominal pain, fever,nausea vomiting.

PAST HISTORY:

Not a known case of diabetes mellitus, hypertension, tuberculosis, epilepsy or any other chronic illness.

No surgical history.

PERSONAL HISTORY:

 Married, 2 daughters 

Diet :mixed (consumes fish and meat)

Appetite: normal ( presently)

Sleep: disturbed 

Bowel and bladder: normal

Addiction : betel, bidi, alcohol 

Allergy: none

Hobbies: watching telivision

Daily routine:

The patient gets up early morning at 5am. After freshing up he takes water, one cup of  lemon tea with biscuits. Then he rides his cycle almost around 5km to reach his bus stand where he is working as a bus driver. By 6:30 am he starts from Siliguri.

Sometimes he takes a 72 hrs shift (West bengal to Assam).

Around 9am he stops his bus for having breakfast which mainly includes rice,dal, vegetables or fish. 

Next stop he takes around 1pm for lunch ( rice and fish). 

His assistant takes up the driving duty from there. At 10pm they finally go for dinner in a restaurant which mainly includes rice ,dal,vegetables or fish.

Later he continues driving till next day morning.

FAMILY HISTORY:

Not significant 

Clinical images:

General examination:

Patient is conscious ,coherent and cooperative and well oriented to time, place , person.

Patient was examined in a well lit room after taking their consent. 

Patient is undernourished.

Pallor- present 

Icterus -absent

Cyanosis-absent

Clubbing-absent

Generalised Lymphadenopathy-absent

Edema-bilateral pedal edema present

VITALS

Temperature : 98.3℉

PR : 90 beats per minute

BP : 100/70 mm of Hg

RR : 22 cycles per minute

SpO2 : 96% room air

Systemic examination

Per abdomen:

Inspection- 

Abdomen is distended , flanks are full, skin is stretched.

No visible peristalsis, scars, sinuses, hermial orifices.

Equal symmetrical movements in all quadrant’s with respiration.

Umbilicus: central

Palpation - 

No local rise of temperature, no tenderness

All inspectory findings are confirmed by palpation, no rebound tenderness, gaurding and rigidity.

Liver and spleen not palpable.

No organomegaly 

Fluid thrill present 

Percussion:

Shifting dullness present 

Auscultation:

Bowel sounds heard 

CVS : 

Jvp not raised 

Inspection:

Shape of chest - elliptical

No visible pulsations

No engorged veins and scars 

Apical impulse not visible

Palpation:

Apex beat present over the left 5th intercostal space 1cm medial to midclavicular line

No parasternal heave

No precordial thrill

No dilated veins

Auscultation:

S1 S2 heard ,No murmurs 

CNS: 

No focal neurological deficits

Cranial nerves,motor and sensory functions intact. 

RR: 

Upper respiratory tarct - normal

Lower respiratory tract-

Inspection:

Chest bilaterally symmetrical,

Shape- elliptical

Trachea- Midline

Palpation:

Trachea is Midline

Normal chest movements

Vocal fremitus is normal in all areas 

Normal vesicular breath sounds

No added sounds

shape of the chest: normal

Investigation: 

Chest xray

USG Abdomen 

Ascitic Fluid:

PHES TEST:

Interpretation:

Ascitic tap - 

Appearance - clear , yellow coloured 

SAAG - 1.65 g/dl

Serum albumin - 2.0 g/dl

Asctic albumin - 0.35 g/dl

Ascitic fluid sugar - 104mg/dl

Ascitic fluid protein - 0.7 g/dl

Ascitic fluid amylase - 17 IU /L

LDH : 143 IU/L 

Cell count- 50 cells 

Lymphocytes nil

Neutrophils 100%.

Provisional diagnosis:

Portal hypertension with ascites 

TREATMENT :

Tab LASIX 40 mg PO BD

Syp. Lactulose 10 ml PO HS

Strict Alcohol abstinence .