A 35 year old male with distended abdomen
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Chronic liver disease
A 35 years old unmarried male,who is a lorry driver by occupation works for every 5 days in a week,resident of anthampet came to opd yesterday with complaints of pain abdomen since 10days,yellowish discolouration of urine since 8 days,distension of abdomen since 6 days,bilateral lower limb swelling since 5 days .
History of present illness
Patient was apparantly assymptomatic 5months ago and then developed,a non healing wound over right foot(not healed for 1 month),for which he was taken to hospital and was diagnosed to be having diabetes (on oral hypoglycaemic drugs) and was assymptomatic 10days ago and then developed,abdominal pain ,which was of dragging type of diffuse pain of the abdomen ,yellowish discolouration of urine since 8 days and abdominal distension and bilateral lower limbs swelling since 6days,which were insidious in onset and gradually progressive, pitting type of edema over bilateral lower limbs,till knees ,and decreased urine output and constipation since 5 days.
10 days ago they went to local hospital in view of abdominal distension and lower limb swelling for which they stayed for 3 days and went home and since then,in view of further progression of edema,and abdominal discomfort,they came here for further management.
No history of fever,vomitings and loose stools.
Past history
K/c/o diabetes mellitus
Not a k/c/o HTN,Tb,Epilepsy,CAD,CVA.
Personal history
Sleep is disturbed since 10days.
Decreased Appetite since 6 days
Mixed diet
Decreased urine output since 5days and not passed stools since 5 days
Started alcohol since 10 years,and increased since 1 year due to death of his mother
His last binge of alcohol was 10days ago.
Chronic smoker since 10 years,stopped 1 week ago.
General examination
Patient was drowsy,not coherent and not cooperative
He is moderately built and moderately nourished
Vitals at presentation
Bp 110/80mmHg measured on right hand
PR: 86bpm
Icterus+,edema present,pitting type till knee.
No pallor,cyanosis,clubbing,lymphadenopathy
PER ABDOMEN
I examined the patient in a well lit room after taking a consent
ON INSPECTION
Abdomen is distended,umbilicus is everted,skin over abdomen is stretched and shiny,no visible pulsations,no engorged veins
PALPATION
No local Rise in temperature,no tenderness
All inspectory findings are confirmed
No guarding and rigidity
No hepatomegaly
No splenomegaly
PERCUSSION
shifting dullness present
No fluid thrill
AUSCULTATION
Sluggish bowel sounds are heard
No bruits
CVS
S1 and S2 present
CNS: patient is drowsy and lethargic
Tremors present yesterday,when he came to opd.
And,yesterday night he was irritable and didn’t slept in the night,and morning he was irritable and was incorporative for treatment and since afternoon he was drowsy.
Provisional diagnosis:
Hepatic encephalopathy
Investigations:
Total bilirubin 7.61mg/dL
Direct bilirubin:5.51mg/dL
AST 97
ALT 37
ALP 457
Total proteins 5.5
Albumin 2.2gm/dL
Urea 21mg/dL
Creatinine 0.6mg/dL
Serum sodium 132mEq/L
Potassium 2.2mEq/L
Chloride 105mEq/L
Magnesium 2
PT 68sec
APTT 132sec
INR 5.0
Hemoglobin 11.3gm/dL
TLC 12,000cells/cumm
Platelets 1.74lakhs/cumm
Complete urine examination (outside shown, excretion of bile salts and bile pigments)
Here the CUE is normal.
Final diagnosis
Chronic liver disease secondary to alcohol with Type 2 diabetes and ?alcohol withdrawal with grade 2 hepatic encephalopathy.
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