Demographic data

• Name : Ramdas
• Age : 30 years
• Sex : Male
• Address: Padalam
• Education : 10th Std
• Occupation : Farmer
• Socio-economic Status : Class 4 of Modified BG
Prasad Classification
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CHIEF COMPLAINTS

• Distension of Abdomen since 1 month

• Swelling of lower limb since 1 week
• Yellowish discolouration of skin and
eyes since 1 week

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HISTORY OF PRESENTING ILLNESS
• The patient was apparently alright 1 month ago. Then he
developed distension of abdomen which was insidious in
onset, gradually progressive, painless and generalised
distension. There are no aggravating or relieving factors.
• H/o B/L pitting edema in lower limbs upto ankle for 1
week.
• No H/o pain abdomen
• No H/o of facial puffiness, oliguria
• No H/o difficulty in breathing, orthopnea, PND
• No H/o vomitting
• No H/o blood in stools

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• The patient also gives history of yellowish discolouration of
skin and eyes since 1 week, acute in onset, gradually
progressive, first noticed in the eyes by patient attenders.
• H/o high coloured urine since 1 week
• No H/o generalised itching, clay coloured stools

• History of decreased apetite since 2 months

• No H/o weight loss, easy fatiguability
• No H/o if fever
• N H/o altered sleep wake pattern or day time drowsiness
• No H/o hematemesis,blood in the stools,
• melena
PAST HISTORY
• H/o similar complaints of abdominal distension, vomitting and
yellowish discolouration of skin and eyes 8 months back for
which he was admitted to the hospital ward and treated with
medications:
• Ursodeoxycholic acid(300mg)
• Sylibon 70mg
• Neurobion
He was relieved and dicharged after 1 week
No H/o Hypertension, Diabetes mellitus, asthma, TB, epilepsy
No H/o chronic drug intake, blood transfusion, tattooing, IV
drug abuse
No H/o intake of any herbal medicine
No H/o surgeries in the past

5
FAMILY HISTORY
• No H/o similar complaints in the family.

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PERSONAL HISTORY
• Diet – Mixed
• Appetite – Reduced
• Sleep – Undisturbed
• Bowel and bladder movements – Regular and
normal.
• H/o alcohol consumption since 10 years-Brandy-
300g/day. Last drink was consumed 1 week ago.
• H/o smoking since 10 years-10 cigerettes/day- 2.5
pack years
• No H/o high risk sexual behaviour
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 SUMMARY
• MrRamdas 30 yr old gentleman who has a history of
alcohol consumption and smoking since 10 years
comes with complaints of generalised distension of
abdomen since 1 month, swelling of lower limbs and
yellowish discolouration of eyes and skin since week.
There is also history of similar complains 8 months
ago which was treated and relieved.
• I would like to consider decompensated - chronic liver
disease.

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GENERAL PHYSICAL EXAMINATION
• The patient is a middle aged male, moderately built and
poorly nourished, is conscious, co-operative and well
oriented to time, place and person.

• Vitals –
 Pulse – 76 bpm normal in rhythm, character and volume, with no
vessel wall thickening. There is no radio-radial or radio-femoral
delay.
 Respiratory rate – 16 breaths per minute
 Blood pressure – 120/80 mmhg (measured in right arm in supine
position)
 Temperature – 98.6⁰ F (measured in the axilla)

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• Height – 170 cms
• Weight – 61 kgs
• BMI – 21.11 kg/m²

• Icterus-Present
• Pallor, Cyanosis, Clubbing, Lymphadenopathy,
Edema: B/L pitting edema in lower limbs upto
ankle.

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HEAD TO TOE EXAMINATION

• Hair- Sparse
• Eyes- Icterus present, No pallor
• Yellowish pigmentation of skin seen
• Resting coarse tremors of hands is present
• No/history of Parotid Swelling, Spider nevi, Palmar
erythema, white nails, flapping tremors, loss of axilary
and pubic hair, Duputryens contracture, Gynacomastia,
testicuar atrophy
• No H/oAngular stomatis ,cheilitis
• Petechia /purpura not seen
 PER ABDOMEN EXAMINATION
• The patient is exposed from nipples to mid-thigh region and
examined in Supine position.
• INSPECTION
• Generalised distension of abdomen seen
• Umbilicus is central in position and inverted
• Corresponding quadrants move equally with respiration
• Dilated torturous veins are seen on both sides of the abdomen
• No scars, sinuses
• Hernial orifices are intact
• External genitalia appear normal
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• PALPATION
• Superficial Palpation
-No local rise of temperature or tenderness.
•Deep Palpation
-No guarding, rigidity
-Liver is palpable, size about 5 cm below the costal margin,
firm in consistency, smooth surface, sharp borders.
-Spleen is palpable 2cm below the costal margin by dipping
method, non tender
-Kidneys not palpable

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 Measurements

Abdominal girth: 96 cm
Xiphysternum to umbilicus: 20 cm
Umbilicus to Pubic Symphysis: 15cm
Umblicus to Anterior superior iliac spine
Right side- 30cm
Left side- 30cm

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• PERCUSSION
• Liver dullness
-Upper border-Fifth right intercostal space on full
expiration
-Lower border: Dullness extends 10 cm below the right
costal margin on mid clavicular line on full expiration
-Liver span: Right lobe- 20 cm
Left lobe-11 cm
Shifting dullness-Present
• AUSCULTATION
• Normal bowel sounds are heard
• No venous hum or arterial bruit
• No bruit heard over liver or spleen
 SYSTEMIC EXAMINATION
Cardio-vascular System –
 S1 and S2 heard.
 No murmurs heard.
 No additional sounds heard.

Respiratory System –
 Normal vesicular breath sounds heard.
 Equal bilateral air entry.
 No added sounds.

Central Nervous System –

 No abnormality detected.
 Higher mental functions normal 17
PROVISIONAL DIAGNOSIS
• Alcoholic liver disease probably early alcoholic
cirrhosis with features of portal hypertension

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INVESTIGATIONS
• Complete Blood Count, Coagulation Profile
• Stool for Occult Blood
• Urine Routine
• Liver Function Tests
• Renal Function Tests
• Ascitic Fluid Analysis
• USG Abdomen
• Upper GI Endoscopy
TREATMENT
• Dietary salt restrictions.
• B Bockers
• Diuretics - spironolactone + furosemide
• Proton Pump Inhibitors
• Paracentesis
• Liver Transplantation
• Abstenience from Alcohol
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