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1. Case presentation
NAME : REKHA S
FINAL YEAR MBBS,
BGS GIMS , BANGALORE

2. Patient particulars
 Name : Mr. Manjunath
 Age : 45 years
 Sex : male
 Education :10 std
 Occupation : water supplier
 Socioeconomic status : lower middle class
Date of admission : 5/10/2021
Date of examination : 11/10/2021

3. Chief complaints
 Abdominal distension since 15 days
 Swelling of lower limbs since 12 days

4. History of presenting illness
 Patient was asymptomatic before 15 days when he developed abdominal
distension which was insidious in onset , gradually progressive , started initially
around the lower abdomen and currently uniform distended abdomen with no
aggravating and relieving factors
 Abdominal distension was not associated with pain abdomen
 He had no h/0 vomiting , constipation
 no h/o breathlessness ,chest pain
 No h/o orthopnea , PND
 No h/o decreased urine output , facial puffiness

5.  Patient complaints of swelling of lower limbs
 Present since 12 days ,insidious in onset , gradually progressive
 Initially noticed around the ankle and currently progressed till thighs
 No aggravating and relieving factors
 No h/o fever
 No h/o pain and redness of limbs
 No h/o breathlessness
 No h/0 decreased urine output

6.  no h/o fever
 No h/o pain abdomen
 No h/o itching , clay coloured stools , high coloured urine
 No h/o vomiting blood , blood in stools
 No h/o breathlessness
 No h/o involuntary movements ,altered sensorium ,change in sleep pattern
 No h/o decreased urine output
 No h/o decreased appetite and weight loss

7. Past history
 He had similar complaints of abdominal distension 10 months back and was
treated for the same and it reduced
 he has no h/o diabetes , hypertension , tuberculosis
 No h/o tattoo, piercing , blood transfusion
 No h/o past surgical intervention

8. Drug history
 He is on antihypertensive drug since a year
 He has no h/o allergies to any drugs in the past

9. Family history

10. Personal history
 He consumes a mixed diet
 Appetite normal
 Sleep – undisturbed
 Bowel and bladder movements : regular
 Addictive habits : he consumes alcohol since 20 years
 whiskey-180 ml / day – 6 units
 No h/o smoking , iv drug abuse

11. Summary
 A 45 year old male who is a chronic alcohol consumer presented with abdominal
distention and swelling of lower limbs with no other complications

12. General physical examination
 Patient s consent was taken
 Patient is well built and nourished
 Patients is conscious ,cooperative and well oriented to time place and person
 Pallor : absent
 Icterus : present
 Cyanosis : absent
 Clubbing : absent
 Lymphadenopathy : absent
 Edema : present till knees – pitting type

13. Vitals
 Pulse : 68 /min normal in rate ,rhythm , character , volume , arteries non palpable
,no delays present
 Blood pressure : 118/80 mm of hg measured in right arm sitting position
 Respiratory rate : 18 cycles / min , thoracoabdominal
 Temperature : afebrile ( 98.4 F)

14. Head to toe examination
 No alopecia
 No loss of eyebrows
 No xanthelasma
no parotid enlargement
 No bad breath
 No spider naevi
 No palmar erythema , dupuytrens contracture
 Nails : normal
 No tremors
 No gynacomastia
 No loss of axillary and pubic hair
 No dilated veins over abdomen

15. SYSTEMIC EXAMINATION
 ABDOMINAL EXAMINATION :
Patient s consent was taken and examined under adequate exposure and light
Inspection :
Generalized distension of abdomen , flanks appear full
Skin is glossy
Umbilicus : everted
All quadrants move equally with respiration
No visible veins , sinuses , scars
No scratch marks

16.  Palpation : done in supine position with both lower limbs flexed
 No local rise of temperature
 No tenderness
 No guarding , rigidity
 Liver palpable : 7 cm below the right costal margin , firm in consistency ,edges are
round ,smooth surface , non tender
 Spleen : non palpable

17.  Abdominal girth : 108 cm
xiphisternum to umbilicus : 39 cm
 umbilicus to pubic symphysis : 24 cm
umbilicus to anterior superior iliac spine :
 right : 38 cm
 left : 38 cm

18.  Percussion :
 Liver dullness
 upper border – fifth intercostal space on full expiration
 lower border – dullness extends 7cm below costal margin in midclavicular line
 Total liver span : 17 cm
 Shifting dullness : present


19.  Auscultation
 Bowel sounds heard – 4 per minute
 No venous hum
 No bruit heard
 Genitilia examination : normal

20.  Respiratory system : Normal vesicular breath sounds heard . No added sounds
 Cardiovascular system : first and second heart sound heard ,no murmurs
 Nervous system examination : no focal neurological deficit . No tremors present

21. Provisional diagnosis
 A 45 year old male with a history of consumption of alcohol since 20 years
presented with abdominal distension and swelling of lower limbs suggestive of
liver pathology and the likely cause is chronic alcohol consumption and my
probable diagnosis is decompensated liver disease with ascites with no features
of its complications .

22. Investigations
 Blood profile
 Liver function tests
 Electrolytes
 Renal function tests
 Ultrasound abdomen
 Hepatic elastography
 Ascitic fluid examination

23. Management
 Diet : high protein diet
 reduced salt intake
 Diuretics
 Liver transplant

24. Thank you