CLINICALS

DR HUSSAIN IBRAHIM
POST GRADUATE-3 YEAR
UNIT-3
Chief Complaints:
A 65 year old female who was a farmer by occupation resident of
Kanchipuram came with chief complaints of abdominal distension
associated with abdominal pain & bilateral lower limb swelling for
the past 15 days.
History of presenting illness
Patient was apparently normal 15 days back then she developed
c/o distension of abdomen x 15 days
-insidious in onset, progressive & uniform in nature, no aggravating &
relieving factors
Associated with c/o abdominal pain over epigastric region
-intermittent ,dull pain with no radiation, no aggravating & relieving
factors
c/o bilateral lower limb swelling for the past 15 days
-insidious in onset, progressive in nature, not a/w pain, not a/w puffiness
of face, aggravated as day progresses and relieved with rest.
-no history of reduced urine output or frothy urine
 c/o breathlessness on exertion (NYHA-CLASS 2),
-insidious in onset, non progressive in nature, aggravated on lying
down, relieved with medical management.
-no history of PND/chest pain/palpitations/syncope
-no history of chronic cough/fever
history of (altered bowel habits ) loose stools 3-4 episodes/day for
the past 7 days, small volume and watery in consistency, not blood
stained, not foul smelling, not associated with vomiting
no history of hematemesis/ malena or other bleeding manifestations
no history of yellowish discolouration of eyes/dark coloured
urine/pale stools/itching
No history of altered sleep pattern
History of loss of appetite and fatiguability present for past 3months
History of loss of weight present( 10kgs in 6months)
No history dysphagia/constipation
Past history
History of frequent hospitalization for complaints of abdominal pain
present(3 times in last 6months)
Known case of coronary artery disease for past 6 months & not on regular
treatment
Known case of carcinoma cervix 30 years back S/P radiotherapy(35 cycles)
Not a known case of Type2 diabetes mellitus/systemic hypertension/thyroid
disorder/bronchial asthma/cerebrovascular events
History of blood transfusion 1 unit done 1 year back
No history of tattooing/native treatment/drug abuse
No history of previous vaccination for hepatitis
Vaccinated for covid 19
Surgical history hysterectomy done 25years back
Personal history
Takes mixed diet
Normal sleep pattern
No history of tobacco or betel nut chewing
Normal bladder habits
Altered bowel habits
Obstetric history
Hysterectomy done 25 years back
P5L4A1
Family history
No history of similar complaints in family members
Summary
A 65 year old female who was a farmer by occupation (25 years back),
with known case of Coronary artery disease/type 2 diabetes
mellitus/Carcinoma cervix S/P radiotherapy came with chief complaints of
abdominal distension associated with abdominal pain & bilateral lower
limb swelling for past 15days
Possible Diagnosis of decompensated liver disease is made
Probable etiology – secondary metastasis to liver, hepatocellular
carcinoma , thrombosis of portal or hepatic vein, metabolic dysfunction
associated steatotic liver disease , cryptogenic cirrhosis.
Since patient had abdominal pain, weight loss and loss of appetite
complications such as spontaneous bacterial peritonitis and
hepatocellular carcinoma to be ruled out.
I would further like to do detailed examination of the abdomen.
On examination:
GENERAL EXAMINATION:
Patient conscious, oriented to time/place/person, emaciated & thin
built
No pallor/no icterus/ no cyanosis/no clubbing/no lymphadenopathy/
bilateral pitting pedal edema + (upto midcalf)
Muddy conjunctiva+/ Arcus senilis+
Signs of liver cell failure
No alopecia
Temporal hallowing present
No bitots spot/ no subconjunctival haemorrhage/ no KF ring/no madarosis
No parotid enlargement
No bleeding gums
No fetor hepaticus
No spider naevi
Breast atrophied
Dilated veins present over abdomen
No dupuytrens contracture/ palmar erythema/flapping tremor/leukonychia
No flapping tremor
Vitals
BP-100/60 mmHg measured in left upper arm, patient in supine
position
PR-90 bpm regular in rhythm normal in volume & character, no
radio-radial & radio-femoral delay, felt in all peripheral vessels and
condition of the vessel wall
RR-16/min thoraco-abdominal type
SpO2-97% under room air
Tempt-97.5 F
JVP – elevated 4 cms from the sternal notch, waveforms normal
Hepato jugular reflex +
Systemic examination
Abdominal examination
ORAL CAVITY:
Tongue- appears normal, no oral ulcer, no bleeding gums, no halitosis
ABDOMEN:
INSPECTION: APPEARS TO BE,
Abdomen uniformly distended with full flanks
Skin over abdomen stretched and shiny
All quadrants move equally with respiration
Visible peristalsis from right to left present
Umbilicus in midline & flushed to the surface, no nodule present
Protrusion of mass above the umbilical area on rising head (divarication of recti )
Dilated veins present over the abdominal wall & chest
No scars & sinuses
PALPATION:
SUPERFICIAL PALPATION
-no warmth, diffuse tenderness present more in the epigastric region
DEEP PALPATION
-By Dipping method, no palpable organomegaly
-Hernial orifice-free
-direction of blood flow in dilated veins is away from umbilicus.
-abdominal girth-75cm , xiphisternum to umbilicus 16cm , umbilicus to pubic
symphysis 12cm , bilateral spino-umblical distance 13cm.
-no palpable inguinal or supraclavicular lymph nodes
PERCUSSION:
Shifting dullness present
By percussion liver dullness present in right 6th intercostal space
Total liver span 10cm ( by palpation lower border of liver felt 2cm
below right midclavicular line)
Traube’s space percussion- resonant
Castell’s and Nixon’s method of percussion doesn't suggest splenic
enlargement
AUSCULTATION:
Bowel sounds present
No bruit/venous hum
Other system examination
CVS- S1 S2 + heard in mitral , tricuspid , pulmonary and aortic area
No murmurs
RS-B/L NVBS+, no added sounds
CNS- GCS 15/15, no focal neurological defecit
No flapping tremors
Summary
A 65 year old female who was a farmer by occupation, with known
case of Coronary artery disease/type 2 diabetes mellitus/Carcinoma
cervix S/P radiotherapy came with chief complaints of abdominal
distension and on examination had signs of liver cell failure such as
ascites , dilated veins.
A Diagnosis of decompensated liver disease with portal hypertension
with no features suggestive of hepatic encephalopathy/ no features
of spontaneous bacterial peritonitis / no gastrointestinal bleeding is
made.
Probable etiology – secondary metastasis, hepatocellular carcinoma ,
thrombosis of portal or hepatic vein, metabolic dysfunction
associated liver disease , cryptogenic cirrhosis.
Management- investigations
Complete blood count with differential count
PT, Aptt, INR
LFT- ALT, AST, GGT, ALP ,serum albumin, Total bilirubin
RFT
serum electrolytes
Abdominal paracentesis - total count, differential count , cytology,
total protein, albumin, culture and gram staining
USG abdomen
cect abdomen
Treatment-
SR diet -2000MG/DAY
RAAS antagonists-SPIRONOLACTONE (100-400MG)
Non-selective beta blockers(CARVEDILOL 3.125MG)
Diuretics(FUROSEMIDE 40-160MG)
TAB RIFAXIMIN 550MG
LACTULOSE
Human albumin
TIPSS
Liver transplant
THANK YOU