1801006028 - Long case
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53 yr old male admitted to opd with chief complaints of
1.Bilateral pedal edema since 20 days
2.Decreased appetite since 20 days
3.Swelling of face since 7 days
Sequence of events:
Patient developed poilo at 6months of age affecting left side of his body(left upper and lower limbs)
At the age of 33 he started drinking alcohol due to family and financial problems.
Recently the patient was apparently asymptomatic 20 days ago.Then he developed Bilateral Pedal edema ( pitting type extending up to the knee)which is insidious in onset and gradually progressive in nature since 1 week.
History of decreased appetite since 20 days
History of constipation since 15 days (once in 3-4 days)
History of decreased urine output since 10 days which is not associated with burning micturation ,yellowish discolouration of urine
History of swelling of facing since 7days
History of Abdominal distension since 7 days
No history of Fever , Vomitings , loose stools,Melena and bleeding tendencies.
No history of hematemesis , itching
No history of Chest pain,Shortness of breath ,Orthopnea, PND.
No history of palpitations.
No history of weight loss.
History of Alcohol consumption since 20 yrs (360ml/day). Last consumption 1 week back.
PAST HISTORY :
History of Poliomyelitis of upper limb and lower limb on left side in early childhood.( At 6 months of age)
Not a known case of Hypertension, Diabetes,TB, Epilepsy, Thyroid disorders.
No past surgical history
Family history:
Patient was born to consanguineous marriage.
Personal history:
Diet: Mixed
Appetite: Decreased since 20 days.
Sleep: adequate
Bowel and bladder movements: Irregular
Chronic Alcoholic since 20 yrs(360ml/day)
No history of allergies
Marital status: Married twice
First marriage: He had 2 sons and 1 daughter
They got divorced and married another women
Second marriage : He had 2 daughters
His parents didn't allow his second wife so he had go to his second wife's house and started living there.
Since then he was seperated from his family.
Daily routine:
Before seperation from family he used to do farming.
He owns a hotel now.
He wakes up at 6 am in the morning and gets ready till 7 am and then goes to hotel .
8 am he starts cooking in his hotel and takes few sips of Alcohol while doing his work.
At 2pm he takes his lunch and then he goes to sleep till 5pm
Then he gets ready and again starts drinking alcohol at 7pm and stops at 8pm
He takes his dinner at 8pm and sleeps around 10 pm
General examination:
Patient is examined in a well lit and ventilated room
Patient is conscious ,coherent and cooperative
Moderately built and nourished
Well orientated to time place and person
Vitals:
Temp: afebrile
BP: 110/70 mm hg
Pulse: 82 bpm
RR: 18cpm
Pallor - present
Icterus - present
Cyanosis- absent
Clubbing- present
Lymphadenopathy - absent
Edema - bilateral pedal edema is seen
Clinical pictures:
SYSTEMIC EXAMINATION:
Per Abdomen:
Inspection:
Shape - distended
Umbilicus - inverted
All quadrants moves equally with respiration
No engorged veins, visible pulsations,scars,sinuses.
Palpation:
All inspectory findings are confirmed
No local rise of temperature
Abdomen is soft and non tender
spleen and liver -not palpable
No other palpable masses
Hernial orifice are free
Percussion:
Shifting dullness is present
Fluid thrill is absent
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
Respiratory system:
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
Percussion: in sitting postion
Rt. Lt
Supraclavicular. N(resonant). N
Infraclavicular. N N
Mammary region. N. N
Inframammary region. N. N
Axillary region. N. N
Infra axillary region. N. N
Supra scapular region. N. N
Interscapular region. N. N.
Infrascapular region. N. N
Auscultation:
Normal vesicular breath sounds
No added sounds
Vocal resonance is normal in all areas
Central Nervous System:
Higher motor functions - intact
Cranial nerves - intact
Motor system:
Power : Rt-UL LL. Lt -UL LL
5/5 5/5. 5/5 5/5
Hand grip. 100%. 0%
Reflexes:
Superficial reflexes:
Babinski: Rt. Lt
positive positive
UL. LL
Biceps. 2+. +2
Triceps. 2+. +2
Supinator. 0 0
Knee 0 2+
ankle jerk cannot be seen due to pedal edema?
Sensory system: intact
Cerebellar functions are normal
Provisional diagnosis:
Ascites secondary to? Chronic liver disease associated with portal hypertension, thrombocytopenia and esophageal varices grade 2 and portal hypertensive gastropathy
Investigations:
Endoscopy video:
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