45/M with abdominal distension and pedal edema

Case: 
45 year old male complaints of abdominal distension and b/l pedal edema (pitting type) , shortness of breath and scrotal swelling 

Chieftain complaints

Patient complaints of 
Abdominal distension 
B/l pedal edema 
Shortness of breath 
Scrotal swelling 
           Since 25 days 

History of presenting illness

Patient was apparently asymptomatic 6 years  back then he had c/o multiple swellings over chest for which he went to hospital and was diagnosed as diabetic and started starting medication since then 
2 years back when he went for routine checkup he was diagnosed as hypertensive and started taking medication 
6 months back patient became unresponsive and speech was reduced and was taken to local hospital where he was found to have low Grbs (27mg/dl ) and also found to have jaundice and was advised to stop alcohol consumption 
Then 25 days back he developed scrotal swelling   , pedal edema (pitting type ) above knee and abdominal distension which was insidious in onset and gradually progressive 
He also c/o sob on exertion since 20 days which progressed now 

Past history 
K/c/o HTN on tab telma 40mg since 2 years 
K/c/o DM since 6 years used tab glibenclamide 5mg + metformin 500mg 
Stopped taking medication since 6 months 


Family history 

Insignificant 

Personal history 

Diet; mixed 
Appetite; normal 
Sleep; adequate 8 hrs per day
Bowel ; regular 
Bladder; regular 
Addictions; chronic alcoholic since 20years -360ml per day stopped drinking since 1 month 
Chronic smoker since 30 years - 2 packs per day 
Occupational history; hotel owner 

General examination 

Patient is conscious coherent and cooperative well oriented to time place and person 
Height; 158cm  
Weight : 
BMI: 
Abdominal girth: 124cm 
Vitals; 
Temp: afebrile 
Pulse rate: 90bpm
Respiratory rate: 22
BP: 130/80
SpO2:98
Pallor, cyanosis, clubbing, are absent 
Edema-pedal( pitting)
Icterus present 

Systemic examination 

CVS: s1 s2 heard no murmurs present 
Respiratory: bilateral normal vesicular breath sounds are present 
CNS: no neurological deficit’s are present 
Abdominal examination:
Inspection: 
Abdominal distension 
Umbilicus everted 
Engorged veins present 
No visible peristalsis 
No scars , sinuses 
Palpitation:
Soft non-tender 
no hepatomegaly or splenomegaly 
Bowel sounds heard 
Percussion : 
Fluid thrill present 
Shifting dullness 



Investigations

Hemogram: 

On 27-10-22:
On 29-10-22: 

         




APTT:


Blood urea:

Serum electrolytes: 

On  27-10-22:


On 29-10-22:        
LFT: 

On 27-10-22: 

On 29-10-22:     
PT:
CUE:

Serum creatinine:
SAAG: 
        

Ascitic fluid amylase: 


Ascitic fluid LDH: 
Ascitic fluid protein sugar : 

      

Chest X-ray:            

Ultrasound abdomen:          
2D ECHO: 

      
Provisional diagnosis: 
CLD with portal hypertension 

Treatment: 

1)Tab Lasix 80 mg po OD 
2)Tab Aldoctone  50mg BD
3)Tab Lactulose 20ml ODHS

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