42 year old male with Abdominal distention and bilateral pedal edema

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

A 42 year old male from Nalgonda district, a Government employee by occupation came to our OPD with 

C/o Abdominal distention since 7 days

      Bilateral Pedal Edema since 3 days

History of Presenting illness

Patient was apparently asymptomatic 10 days ago then he developed Abdominal discomfort which increased on taking food 

Patient developed gradual Abdominal Distention 1 week back which was associated with Shortness of breath even on sitting and while talking

Patient has complaints of burning sensation of legs and hands for the past one week for which he visited a Neurosurgeon at Nalgonda and was prescribed Gabapentin on the provisonal duagnosis of Sensory Axonal Neuropathy. Patient achieves short term relief with the medication.

3 days back patient noticed bilateral mild pedal edema on his way to office which increased by the end of the day and still persists.

Past History

Patient had H/o Jaundice 2 years back which was diagnosed on admission for Dengue hemorrhagic fever and was unconscious for about 3 days.

Not a k/c/o Diabetes mellitus, Hypertension, TB, Epilepsy, Asthma, CAD.

Personal history

Diet is mixed

Appetite is decreased 

Sleep - Inadequate for the past 10 days but improved after taking Gabapentin for burning sensation of legs and hands

Bladder movements - Decreased urinary flow, dark coloured, foul smelling urine with burning sensation post micturition for the past 10 days.

Bowel movements every 2 days

Addictions - Chronic Alcoholic for the past 6 years and consumes more than 180ml whiskey every day.

No habit of Cigarette smoking.

History of weight loss in the past 2 years of about 20 kgs (70kgs to 50 kgs)

Family history- No similar complaints in the family

Drug History  - On Gabapentin for the past 5 days

Surgical history  - Underwent Appendicectomy surgery 17 years back

Daily Routine 

Patient usually wakes up at 5am everyday and goes to work around 9am skips breakfast and has lunch around 4pm. He suffers with hunger pain in the epigastrium during early afternoon which radiates to the back and chest. Drinks alcohol at night and skips meals most of the times and sleeps around 11pm.

General Physical Examination 

Patient was Conscious, Coherent and Cooperative.

Well oriented to time, place and person. 

Undernourished and under built.

Pallor present 

No Icterus, Cyanosis, Clubbing,  Koilonychia, Generalised Lymphadenopathy

Bilateral Pedal edema present of Grade 2.

Vitals

Temperature - Afebrile 

Pulse - 90 bpm

Respiratory rate - 22 cpm

Blood pressure  - 120/80 mmHg

Systemic examination 

CVS - S1,S2 heard

RS - BAE +

CNS - No focal neurological deficits

Abdomen

On Inspection 

Abdomen is distended

Flanks are full

Umbilicus is central and inverted 

Skin is stretched with Dilated veins on sides of the Abdomen 

Appendicectomy scar present 

On Palpation

Soft

Mild tenderness over Right Hypochondriac region 

Liver not palpable 

Spleen not palpable

On Percussion 

Shifting dullness present 

Liver span was difficult to percuss due to distended abdomen.

Provisional Diagnosis 

Ascites secondary to Chronic Liver Disease

Investigations 

Hemogram

RBS, HbA1c

CUE

LFT

serum Creatinine 

Urea

Serum electrolytes

ECG

Chest X Ray PA view 

USG Abdomen 

PT, INR 

APTT

BT, CT

Ascitic tap 

Management 

Fluid restriction to <1 L/day

Salt restriction to <2 gm/day

Inj. LASIX 40mg IV BD

Syrup Lactulose 30ml PO

BP/ PULSE/ RR/ TEMP Charting 4th hourly.