35 year old male with distended abdomen

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Chronic liver disease 

A 35 years old unmarried male,who is a lorry driver by occupation works for every 5 days in a week,resident of anthampet came to opd yesterday with complaints of pain abdomen since 10days,yellowish discolouration of urine since 8 days,distension of abdomen since 6 days,bilateral lower limb swelling since 5 days .

History of present illness 

Patient was apparantly assymptomatic 5months ago and then developed,a non healing wound over right foot(not healed for 1 month),for which he was taken to hospital and was diagnosed to be having diabetes (on oral hypoglycaemic drugs) and was assymptomatic 10days ago and then developed,abdominal pain ,which was of dragging type of diffuse pain of the abdomen ,yellowish discolouration of urine since 8 days and abdominal distension and bilateral lower limbs swelling since 6days,which were insidious in onset and gradually progressive, pitting type of edema over bilateral lower limbs,till knees ,and decreased urine output and constipation since 5 days.

10 days ago they went to local hospital in view of abdominal distension and lower limb swelling for which they stayed for 3 days and went home and since then,in view of further progression of edema,and abdominal discomfort,they came here for further management.

No history of fever,vomitings and loose stools.

Past history 

K/c/o diabetes mellitus 

Not a k/c/o HTN,Tb,Epilepsy,CAD,CVA.

Personal history 

Sleep is disturbed since 10days.

Decreased Appetite since 6 days

Mixed diet

Decreased urine output since 5days and not passed stools since 5 days 

Started alcohol since 10 years,and increased since 1 year due to death of his mother

His last binge of alcohol was 10days ago.

Chronic smoker since 10 years,stopped 1 week ago. 

General examination 

Patient was drowsy,not coherent and not cooperative 

He is moderately built and moderately nourished 

Vitals at presentation 

Bp 110/80mmHg measured on right hand 

PR: 86bpm

Icterus+,edema present,pitting type till knee.

No pallor,cyanosis,clubbing,lymphadenopathy

PER ABDOMEN 

I examined the patient in a well lit room after taking a consent 

ON INSPECTION 

Abdomen is distended,umbilicus is everted,skin over abdomen is stretched and shiny,no visible pulsations,no engorged veins 

PALPATION 

No local Rise in temperature,no tenderness 

All inspectory findings are confirmed 

No guarding and rigidity 

No hepatomegaly 

No splenomegaly 

PERCUSSION 

shifting dullness present 

No fluid thrill 

AUSCULTATION 

Sluggish bowel sounds are heard 

No bruits 

CVS

S1 and S2 present 

CNS: patient is drowsy and lethargic 

Tremors present yesterday,when he came to opd.

And,yesterday night he was irritable and didn’t slept in the night,and morning he was irritable and was incorporative for treatment and since afternoon he was drowsy.

Provisional diagnosis:

Hepatic encephalopathy 

Investigations:

Total bilirubin 7.61mg/dL

Direct bilirubin:5.51mg/dL

AST 97

ALT 37

ALP 457

Total proteins 5.5

Albumin 2.2gm/dL

Urea 21mg/dL

Creatinine 0.6mg/dL

Serum sodium 132mEq/L

Potassium 2.2mEq/L

Chloride 105mEq/L

Magnesium 2

PT 68sec

APTT 132sec

INR 5.0

Hemoglobin 11.3gm/dL

TLC 12,000cells/cumm

Platelets 1.74lakhs/cumm

Complete urine examination (outside shown, excretion of bile salts and bile pigments)

Here the CUE is normal.

Final diagnosis 

Chronic liver disease secondary to alcohol with Type 2 diabetes and ?alcohol withdrawal with grade 2 hepatic encephalopathy.