31 year old came with chief complaints of abdominal distension and stomach pain

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Chief complaints:- A 31 year male patient  came with chief complaints of abdominal pain since one year and yellowish discolouration of sclera since 1 week.

 

                                                                     

                                                                                                             

History of presenting illness:- Patient was apparently asymptomatic 2 years back then he developed abdominal distension which is insidious in onset and gradually progressive in nature and subsequently noticed bilateral swelling of lower limbs, he also developed yellowish discolouration of sclera for which he went to near by hospital and was diagnosed with fatty liver and was treated

One and half year back he developed jaundice, abdominal pain, abdominal distension and pedal edema for which he went to NIMS Hyderabad hospital , he was admitted and paracentesis was done and discharged .

6 months back he had 4 episodes of hematemesis per day for 2 days and 4 episodes of melena per day for 2 days for which he went to NIMS and was diagnosed with oesophageal varices for which endoscopic variceal ligation was done.

30 days back he again developed yellowish discolouration of sclera and was treated in our hospital for 5 days .

Since past 7 days he had severe abdominal pain in right hypochondriac region, epigastric region and left hypochondriac region and also increase in yellowish discolouration of sclera since 1week.

-H/0 of fever, low grade, intermittent in nature not associated with chills.

-H/0 of anorexia, fatigue and generalized weakness since 3 months.

-H/0 of disturbed sleep since two month, where he complained of excessive day time sleepiness and night distured sleep.

-No h/0 of nausea and vomitings.

-No h/0 of pain abdomen.

-No h/0 of decreased urine output.

-No h/0 of high coloured urine and coffee coloured stools.

-No history of shortness of breath.

Past history:- History of abdominal distension , swelling of bilateral pedal oedema, and hematemesis one episode 50 ml 18 months back ,where he admitted in an hospital for 10 days which relieved with diuretics , abdominal paracentesis and gastric oesophageal ligation was done.

-No history of hypertension, diabetes, thyroid , epilepsy or seizure disorder.

Personal history- 

Diet - mixed

Sleep - disturbed , excessive day time sleep , night time disturbed sleep since two months. 

Appetite- decreased.

Bowel and bladder movements - regular and normal.

Habits- chronic consumption of alcohol since 20 years daily , consumes around half bottle of whiskey in one week.

General examination - Moderately built and nourished.

Patient is oriented to time , place and person.

VITALS - 

Pulse - 82 beats per minute

Blood pressure - 100/70 mm Hg

Respiratory rate - 17 cpm 

Spo2- 98 % on room air

Physical examination- 

pallor - present

Icterus - absent

No cyanosis

No clubbing

No generalized lymphadenopathy

Pedal edema - present.

Inspection :-

Oral cavity - No dental caries and no Tobacco staining

Abdomen - flanks full, distension.

Appendicectomy scar present.

Distened veins present.

No visible peristalsis or no visible pulsations.

Palpation :-

Done in supine position with Both Limbs flexed and hands by side of body.

No tenderness or local rise of temperature.

Abdomen - soft.

Hepatomegaly present and liver is firm on palpating.

Spleen not palpable 

Kidneys bimanually palpable , ballotable.

Fluid thrill - present

Auscultation :-

Normal bowel sounds heard.

No hepatic bruit , venous hum or friction rub.

Provisional diagnosis - 

chronic liver disease with portal hypertension.

Investigations:-

CBP :- 

HB - 8.7

TLC - 21000

PLT - 2.7 LAKH

LFT:-

Total bilirubin - 15.9 mg/ dl

Direct bilirubin - 8.65 mg/dl

SGOT - 57 IU/L

SGPT - 16 IU/L

ALP - 207 IU/L

Total protein - 6.4 gm/dl

Albumin - 2.06 gm/ dl

PT - 18 Sec.

APTT - 35sec.

INR - 1.33

BGT AB+

Hiv - negative.

Hbsag -negative.

Hcv - negative

ULTRASOUND REPORT:-