Scribd Logo
Upload

Welcome to Scribd!

  • 10 views

    Case

    Uploaded by

    med.student657
    This document contains a medical history and examination of a 48-year-old male patient presenting with abdominal distension, swelling of the lower limbs, and pain around the umbilical region for 20 days. The patient has a history of similar episodes in the past and alcohol consumption. On examination, the patient has pallor, icterus, edema of the lower limbs, abdominal distension with fluid thrill, and signs of chronic liver disease and portal hypertension. The diagnosis is chronic liver disease with Grade IV ascites and signs of portal hypertension and hepatocellular failure.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Case

    Uploaded by

    med.student657
    10 views13 pages
    This document contains a medical history and examination of a 48-year-old male patient presenting with abdominal distension, swelling of the lower limbs, and pain around the umbilical region for 20 days. The patient has a history of similar episodes in the past and alcohol consumption. On examination, the patient has pallor, icterus, edema of the lower limbs, abdominal distension with fluid thrill, and signs of chronic liver disease and portal hypertension. The diagnosis is chronic liver disease with Grade IV ascites and signs of portal hypertension and hepatocellular failure.

    Original Title

    case ppt

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document contains a medical history and examination of a 48-year-old male patient presenting with abdominal distension, swelling of the lower limbs, and pain around the umbilical region for 20 days. The patient has a history of similar episodes in the past and alcohol consumption. On examination, the patient has pallor, icterus, edema of the lower limbs, abdominal distension with fluid thrill, and signs of chronic liver disease and portal hypertension. The diagnosis is chronic liver disease with Grade IV ascites and signs of portal hypertension and hepatocellular failure.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    10 views13 pages

    Case

    Uploaded by

    med.student657
    This document contains a medical history and examination of a 48-year-old male patient presenting with abdominal distension, swelling of the lower limbs, and pain around the umbilical region for 20 days. The patient has a history of similar episodes in the past and alcohol consumption. On examination, the patient has pallor, icterus, edema of the lower limbs, abdominal distension with fluid thrill, and signs of chronic liver disease and portal hypertension. The diagnosis is chronic liver disease with Grade IV ascites and signs of portal hypertension and hepatocellular failure.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 13

    Patient name : Mahadev Shinde.

    Age : 48 years. Sex : Male


    Occupation : Machine operator Address : Belagavi
    Religion : Hindu
    Ward : G + 3 free ward
    CHIEF COMPLAINTS

    1. Abdominal distension since 20 days


    2. Swelling over lower limbs since 20 days
    3. Pain around umbilical region since 20 days
    HISTORY OF PRESENTING ILLNESS
    Patient was apparently alright 20 days , when he developed distension of
    abdomen which was insidious in onset and progressive in nature. It first appeared
    around the umbilicus and progressed to the whole abdomen.

    Patient also complains of swelling over lower limbs which was insidious in onset
    and progressive in nature. The swelling progressed from ankles up to the knee in
    the span of 20 days. It was painless in nature and there is no diurnal variation. The
    swelling aggravates on doing work at day time.

    Patient also complains of pain over the umbilical region which was insidious in
    onset and progressive in nature , it was dull type of pain, non-radiatin, aggravated
    on doing work and relief on taking rest.
    The pain was associated with moderate fever, which was insidious in onset.

    No history of chills and rigor.

    Patient also complains of breathlessness on doing routine work

    History of hematemesis 15 days back

    History of bleeding through rectum - 2 episodes in 3 months

    No history of of melena , diarrhoea , foul smelling stools , reduced micturition or


    loss of weight.
    PAST HISTORY
    The patient had 4 episodes of similar complaints in the past.

    The 1st episode was in August 2019, for which he was admitted to KLE
    Hospital,Yellur where tapping was done and 3.5 ltr fluid was removed.

    The symptoms reappeared after a span of 2 months, which he showed in KLE


    Hospital, Belagavi. He was given medication and found relief.

    Then 3rd episode came in the month of December and the final episode
    occurred in January.
    Patient has undergone appendectomy

    Not a known case of diabetes mellitus, hypertension , tuberculosis

    No history of blood transfusion

    No history of jaundice

    FAMILY HISTORY - nothing significant


    PERSONAL HISTORY
    Diet - Mixed. Appetite - Normal. Sleep - Reduced.

    Bladder - Reduced. Bowel - Reduced.

    Habits - History of alcohol intake one quarter per day ( whiskey) since 9 years

    1 quarter = 180 ml

    (180*40) / 100 = 72 gm per day

    History of tobacco chewing since 10 years, three packets per week


    GENERAL PHYSICAL EXAMINATION
    Patient is 48 years old male, who is moderately built and moderately nourished.
    He is conscious, cooperative and well oriented to time, place and person.

    VITALS - PR - 92 beats per minute. BP - 110/90 mm of Hg

    RR - 16 cycles per minute. Temperature - Afebrile

    Pallor - present. Icterus - present. Cyanosis - absent. Clubbing - absent

    Lymphadenopathy - absent. Edema - absent


    HEAD TO TOE EXAMINATION

    Scalp - grey hair , lustrous. Eyes - Pallor and icterus present , pupils normal

    Nose - normal. Face - normal. Ears - normal

    Mouth and oral cavity - normal.

    Lower limb - bilateral pitting type oedema present till knee

    Chest - gynaecomastia present

    Abdomen - umbilicus horizontally stretched , uniformly distended , no prominent


    veins seen
    SYSTEMIC EXAMINATION

    Abdomen - shape - uniformly distended , flanks full

    Respiratory movement - abdominothoracic.

    No visible peristalsis , umbilicus inverted , prominent veins absent , hernial


    orifices absent

    Operation scars for appendectomy present

    No pigmentation , no branding marks


    Signs of hepatocellular failure

    Alopecia - present. Parotid swelling - absent. Gynecomastia - present

    Spider navi - absent. Jaundice - present. Palmar erythema - present

    Clubbing - absent. Loss of shaving tendency - present

    Loss of axillary , pubic , chest hair- present


    Palpation -

    Superficial - tenderness absent , no guarding , no rigidity

    Deep - no organomegaly

    Percussion -

    Fluid thrill present ( Grade IV ascites)

    Auscultation -

    Normal bowel sounds heard


    Respiratory system - Normal vesicular breath sounds heard

    Cardiovascular system - Heart sounds S1 + S2 heard normally , no added


    sounds heard

    CNS - All sensory and motor functions of the patient are intact

    DIAGNOSIS - Chronic liver disease with Grade IV ascites with signs of


    portal hypertension and hepatocellular failure

    You might also like