PRESENTER

DR. MUNNA RANI DEB

PHASE-A RESIDENT
 PARTICULARS OF THE PATIENT
 Name : Md. Parvez Ahmed
 Age : 23 years
 Sex : Male
 Marital status : Unmarried
 Religion : Islam
 Address : Komolgonj, Moulvibazar
 Occupation : Bus driver
 Date of admission : 21.01.2020
 Date of examination : 22.01.2020
 CHIEF COMPLAINTS
 Pain in the right upper abdomen for 14 days
 Abdominal distension for 14 days
 HISTORY OF PRESENT ILLNESS
According to the statement of the patient, he was
reasonably well about 14 days back. Since then he
has been suffering from pain in the right upper
abdomen which is constant & dull aching in nature
without any radiation. Pain has no aggravating or
relieving factors. He has also been suffering from
abdominal distension for the same duration which
was progressive in nature. On further query he also
complained of low grade intermittent fever specially
at evening which was associated with night sweats &
dry cough for last 1 month. He lost about 13 Kg
weight over a period of last 1 year. He has no history
of chest pain, breathlessness, hematemesis,
melaena, abnormal behavior, slurred speech,
confusion, convulsion. He has no history of previous
blood transfusion, sharing of needle or tattooing or
any unprotected sexual exposure. His bowel &
bladder habit is normal.
 HISTORY OF PAST ILLNESS
 He has history of jaundice about 8 years ago which
was treated by a local physician.
 No history of HTN, DM, IHD
 FAMILY HISTORY
 He has his parents, 2 brothers & 2 sisters. All are
alive & in good health.
 No similar type of disease is present in his family
 TREATMENT HISTORY
 He took some drugs for these complaints from
local pharmacy but he couldn’t mention the name
of the drugs.
 PERSONAL HISTORY
 He is a non smoker, non alcoholic.
 He has no history of any IV drug abuse.
 No history of contact with TB patient.
 IMMUNIZATION HISTORY
 He is immunized as per EPI schedule but not
vaccinated against Hepatitis B virus.
 SOCIO-ECONOMIC HISTORY
 He came from a lower middle income family.
 He lives in a semi pakka house, drinks tubewell
water & use sanitary latrine.
 GENERAL EXAMINATION
 Appearance : Ill looking
 Body built : Average
 Co-operation : Co-operative
 Decubitus : On choice
 Nutritional status : Normal
 Anemia
 Jaundice
 Cyanosis Absent
 Oedema : Present
 Dehydration Absent
 Clubbing
 Koilonychia
 Leukonychia
 Skin condition : Normal
 Hair distribution : Normal
 Flapping tremor : Absent
 Palmar erythema : Absent
 Fetor Hepaticus : Absent
 Breast : Normal
 Pulse : 76 bpm, Regular
 BP : 110/70 mm of Hg on lying position
 Respiratory Rate : 18 breaths/min
 Temperature : 99°F
 Lymph nodes : Not palpable
 Parotid glands : Not enlarged
 Thyroid gland : Not enlarged
 Neck vein : Not engorged
 Bed side HCT : Nil
 Bed side ESR : 40 mm in 1st hour
SYSTEMIC EXAMINATION
 ALIMENTARY SYSTEM
Oral cavity : Normal.
Abdomen:
Inspection :
 Shape of abdomen: Distended.
 Flanks : Full
 Umbilicus : Centrally placed, transversely slit.
 Visible engorged veins : Absent
 Scar mark : absent
Palpation:
 Abdomen is soft
 Fluid thrill: Absent
 Liver : Not palpable.
 Spleen : Not palpable
 Kidney : Not ballotable
 Genitalia : both testis are normal.
Percussion :
 General percussion note of the abdomen:
Tympanitic in midline, dull in the flanks.
 Shifting dullness : Present.

Auscultation:
 Bowel sound : present
 Hepatic bruit and rub : Absent.
 RESPIRATORY SYSTEM
Inspection:
 Shape of chest: Normal.
 Movement of chest: Restricted on right side.
 No visible scar mark, impulse, engorged vein.
Palpation:
 Trachea: Centrally placed.
 Apex beat: In the left 5th intercostal space just
medial to left mid-clavicular line.
 Vocal fremitus: Reduced in right side from 4th
intercostal space downwards in MCL, 5th ICS
downwards in MAL & infrascapular line.
 Chest expansibility : Reduced in right side
Percussion:
 Percussion note: dull on right side in above
mentioned area.
Auscultation:
 Breath sound: absent over right side in above
mentioned area. In other areas - vesicular
 Vocal resonance: absent over right side in above
mentioned areas
 Added sound : absent
 CARDIOVASCULAR SYSTEM
Pulse: 76 beats/min.
Blood pressure: 110/70 mm Hg.
JVP : not raised
Precordium:
Inspection:
 Not bulged, no visible apical impulse, scar mark,
venous engorgement.
Palpation:
 Apex beat in the left 5th intercostal space just
medial to left mid-clavicular line.
 No thrill, left parasternal heave, palpable P2,
epigastric pulsation.
Auscultation:
 1st & 2nd heart sound audible in all 4 auscultatory
areas.
 Murmur absent.
 All other systemic examination revealed normal
findings.
 SALIENT FEATURE
Md. Parvez Ahmed, 23 years old, non smoker,
normotensive, not known to be diabetic, non
alcoholic, bus driver, hailing from Komolgonj,
Moulvibazar, admitted in SOMCH in medicine ward
through out patient department, presented with
pain in right upper abdomen for 14 days, abdominal
distension for same duration. Abdominal pain was
constant dull aching in nature without any
radiation. There was no aggravating or relieving
factors. On query he also complaints of low grade
intermittent fever specially at evening, associated
with night sweats and dry cough for 1 month. He lost
approximately 13 kg weight for last 1 year. He has no
history of chest pain, haemoptysis, breathlessness.
No history of haematemesis, melaena, abnormal
behavior, confusion, convulsion. No history of blood
transfusion, I/V drug abuse, sharing of needle or
tattooing. He has history of jaundice about 8 years
ago which was treated by a local physician. His
bowel and bladder habit was normal. On general
examination patient was ill looking with average
body built & nutritional status, non anaemic, non
icteric. There was no stigmata of chronic Liver
disease or any lymphadenopathy. His pulse rate was
76 bpm, BP was 110/70 mm of Hg, respiratory rate
was 18 br/min, temp was 99 °F. On systemic
examination his abdomen was distended, flanks
were full, umbilicus
was transversely slit, shifting dullness was present.
His chest movement was restricted on right side &
chest expansibility was reduced on right side. Vocal
fremitus was reduced in right side from 4th
intercostal space downwards in MCL, 5th ICS
downwards in MAL & infrascapular line. Percussion
note was dull, breath sound was absent & vocal
resonance was absent on the above mentioned area.
All other systemic examination revealed normal
findings.
PROVISIONAL DIAGNOSIS

?
 Differential diagnosis:

 Disseminated tuberculosis.
 CLD with portal hypertension
INVESTIGATIONS
Complete Blood Count (22.01.20)
 Hb : 15 g/dl
 ESR : 05 mm in 1st hour
 TC of WBC : 5,130/cmm
 DC of WBC
Neutrophil : 82.3%
Lymphocyte: 10.9%
Monocyte : 4.5%
Eosinophil : 2.3%
 Platelet : 4,44,000/cmm
 CBG : 119 mg/dl
 S. Electrolytes
sodium : 136.9 mmol/L
potassium : 4.38 mmol/L
chloride : 104.5 mmol/L
 S. Creatinine : 0.97 mg/dl
 S. Bilirubin : 0.90 mg/dl
 SGPT : 30 IU/L
 Prothrombin time : 18 sec
 S. Albumin : 3.65 gm/dl
 Viral markers:
HBsAg
Anti HCV Negative
Anti HBc (Total)
 Fasting lipid profile :
Total cholesterol : 158 mg/dl
Triglyceride : 130 mg/dl
HDL : 40 mg/dl
LDL : 92 mg/dl
 S.TSH : 1.48 IU/ml (normal= 0.47-5.01 IU/ml)
 S. Lipase : 347 IU/L
 Urine R/E
albumin : trace
sugar : nil
epithelial cell : 0-1 /HPF
RBC : nil
pus cell : 0-2/HPF
 USG of whole abdomen :
Moderate to huge ascites with internal septation.
Right sided mild pleural effusion.
 CT scan of abdomen :
Loculated & minimal free intraperitoneal collection
with extension into pelvic cavity.
Right sided mild pleural effusion.
 Upper G.I. tract Endoscopy :
Congestive gastropathy.
 Ascitic fluid study :
Wet film
RBC : plenty /HPF
WBC : 30-40 /HPF
TLC = 300/cmm
DLC(Leishman stain) = all cells are lymphocytes.
Pap’s stain : malignant cell not found
ADA : 37 IU/L
Protein : 5.10 g/dl
 Pleural fluid study :
ADA : 45.3 IU/L
Protein: 5000 mg/dl
Sugar : 124.2 mg/dl