1. CASE PRESENTATION
Dr. Samia Farhin
Intern Doctor (Batch: TM-09)
Department Of Medicine
Tairunnessa Memorial Medical College
2. PARTICULARS OF PATIENT
Name : MD. Abul Kalam
Age : 55 years
Sex : Male
Religion: Islam
Marital Status: Married
Occupation : Farmer
Present Address : Bhola Sadar,Bhola.
Permanent Address: Bhola Sadar,Bhola.
Date Of Admission : 13/12/2016 ; at 11.00 a.m.
Date Of Examination : 13/12/2016 ; at 11.30 a.m.
3. Generalized abdominal swelling with discomfort for
2 months.
Scanty micturition with constipation for 1 month.
CHIEF COMPLAINTS
4. HISTORY OF PRESENT ILLNESS
According to the statement of
patient,he was reasonably well about 2
months back.Since then,he had been suffering
from generalized gradual abdominal swelling
which was increased progressively over last
15 days.It was associated with epigastric
discomfort with sense of heaviness.He also
complained of scanty micturition, constipation,loss
of appetite,malaise & generalized weakness for 1
month.On query,he had disordered sleep rhythm
for 15 days & loss of libido for some duration.
5. ‘CONTINUED’
He suffered from jaundice about 6 months back &
at that time,he took some herbal medications .
There was no history of haematemesis,melaena or
loss of consciousness.He didn’t give any history of
fever,shortness of breath,cough,puffiness of
face,joint pain,skin rash,or pigmentation.
Then he had admitted in this hospital for
proper management.
6. HISTORY OF PAST ILLNESS
He was nondiabetic,normotensive.He
had no history of blood transfusion,I/V drug
abuse,sharing of needles or unsafe sexual
exposure.He didn’t have any other significant
medical or surgical illness.
7. DRUG & TREATMENT HISTORY
He was taking anti viral drugs,
B- adrenoceptor blocking agents & diuretics for
about last 1 month.He hadn’t any other significant
drug or treatment history.
8. FAMILY HISTORY
His father & mother has been died
due to geriatric illness.He had no family history of
liver disease,hypertension,diabetes or any other
familial diseases.His family member was five
including his wife.All of them are alive & healthy.
9. PERSONAL HISTORY
He was non-smoker,non-alcoholic but
habituated with betel leaf & betel nut chewing for
about 20 years.
17. “CONTINUED”
Deep :- ⭕Liver & Spleen : not palpable.
⭕Kidneys : not ballot able
⭕Para aortic lymph node : couldn’t examine due
to ascites.
⭕Testes : both were small & soft,non-tender
⭕Hernial orifices : intact
Percussion :- ⭕ Shifting Dullness : Present
⭕Fluid thrill : Present
Auscultation :- ⭕Bowel Sound : Present
18. “CONTINUE”
Examination Of Nervous System:
A)Higher Psychic Function:
1.Appearance & Behaviour : Ill looking, anxious
2.State of Consciousness : Good
3.Orientation with time,place & person: Oriented
4.Memory : A slight tendency of
forgetfulness
5.Emotional state : Good
6.Speech & language : Normal
B)Examination Of All Cranial Nerves:
1.Olfactory Nerve : Intact
2.Optic Nerve : Intact
3.Oculomotor Nerve : Intact
4.Trochlear Nerve : Intact
5.Trigeminal Nerve : Intact
6.Abducent Nerve : Intact
7.Facial Nerve : Intact
8.Vestibulo-cochlear Nerve : Intact
9.Glossopharyngeal nerve : Intact
10.Vagus Nerve : Intact
11.Accessory Nerve : Intact
12. Hypoglossal Nerve : Intact
19. “CONTINUE”
C)Motor Functions:
1.Bullk of the muscle: Normal
2.Tone of the muscle: Normal
3.Power of the muscle: Normal
4.Involuntary movement (Tremor) : Absent
5.Coordination test : Coordinated
6.Gait & Posture : Normal
7.Reflexes (Superficial & Deep) : Intact
D)Sensory Functions:
1.Sense of touch : Intact
2.Pain sensation : Intact
3.Temperature : Intact
4.Position Sense : Intact
E)Signs Of Meningeal Irritation:
1.Neck Rigidity : Absent
2.Kernig’s Sign : Absent
3.Brudzininski’s Sign : Absent
20. “CONTINUE”
Examination Of Cardiovascular System:
Pulse : 78 b/min;regular;catacrotic;condition of vessel wall is normal.
Neck Veins : JVP not Raised
Blood Pressure : 120/70 mmhg
Precordium:
Inspection: ⭕ Any Chest Deformity : Absent
⭕Visible Cardiac Impulse : Absent
⭕Any Scar Mark : Absent
Palpation:
⭕Apex Beat : Left 5th intercostal space,9 cm away from midline
⭕Thrill : Absent
⭕ Left Parasternal heave ; Absent
⭕ Palpable P2 : Absent
Auscultation:
1st & 2nd heart sounds are audible in all auscultatory area.There
is no murmur or any other added sound.
21. “CONTINUE”
Examination Of Respiratory System:
Inspection:
⭕ Shape of the chest: elliptical, bilaterally symmetrical.
⭕ Movement of the chest : Regular
⭕ Respiratory Rate : 16 b/min
⭕Visible impulse,scar mark,engorged vein: absent
Palpation:
⭕ Trachea: Central in position
⭕ Chest expansibility: Normal
⭕ Vocal fremitus : normal
⭕ Rib tenderness : Absent
Percussion:
⭕Percussion note : Resonant
Auscultation:
⭕ Breath sound: Vesicular
⭕Vocal resonance : Normal
⭕ Added sound : Absent
22. SALIENT FEATURES
Mr.Abul Kalam,a 55 years old
muslim,married,farmer; normotensive,nondiabetic,
non-smoker,non-alcoholic gentleman; hailing from
Bhola; presented with generalized gradual abdominal
distension for 2 months & scanty micturition with
constipation,loss of appetite, malaise, generalized
weakness for 1 month.On query, he had disordered
sleep rhythm with loss of libido for some duration.He
suffered from jaundice about 6 months back ,but had
23. “CONTINUE”
no history of blood transfusion,I/V drug abuse,needle
sharing or unsafe sexual exposure.He had no positive
family history of liver disease & not immunized by
hepatitis-B vaccine.He was taking anti-viral drugs,
B-adrenoceptor blocking agents & diuretics for about
1 month.
On examination,he was emaciated, anxious with
hepatic facies,mildly anaemic & mildly icteric.
24. “CONTINUE”
Leuconychia was present but had no flapping
tremor or palmer erythema.He was oriented in
time,place & person but had a slight tendency to
forgetfulness . His abdomen was distended
but soft,non-tender & had no visible superficial
engorged vein.There was no palpable organomegaly
but shifting dullness & fluid thrill was present.
Examination of other systems reveals no
abnormality.
29. INVESTIGATIONS
NAME RESULT
1.USG of whole
Abdomen
Liver: Normal in size,irregular outline & course
echotexture.Intrahepatic biliary channels are not
dialeted,Intrahepatic vessels are poorly visualized.
Spleen: Normal in size & uniform echotexture.
COMMENT: CLD with Moderate Ascites.
2. S. Total Protein 2.40 gm/dl (normal: 6 – 8.3 gm/dl)
3.Prothrombin
Time
13.9 sec
4. INR 1.16
5. ISI (international
sensitivity index)
1.05
6.S. Bilirubin 1.40 mg/dl
7.SGPT (ALT) 218 U/L
8. SGOT (AST) 89 U/L
30. NAME RESULT
9.Upper GI Endoscopy Oesophagus: 4 column of varices seen,without any active
bleeding point.
Body & Fundus of Stomach: signs of congestive
gastropathy (Rugal folds are enlarged with snake skin like
appearance.)
IMPRESSION: - Non bleeding O.V. within grade 2-4
-Portal hypertensive
gastropathy
10. HBsAg POSITIVE
11. HBeAg Positive
12. CBC with ESR HB% : 7.9 g/dl ; ESR : 45 mm/1st hour
T. RBC Count : 4.23 m/µl
(PCV: 27% ; MCV: 64 fl; MCH: 19 pg; )
T. WBC Count : 6,000 /cumm
(Neutrophils : 55%)
Platelet count : 2,11,000 / cumm
13. S. Creatinine 1.32 mg/dl
14. S. Electrolytes S.Na+ : 128.60 mmol/l; S.Cl- : 104.0 mmol/l
S. K + : 4.08 mmol/l
31. Plan Of Investigations :
Ascitic fluid aspiration & study :
# Total albumin & protein (to calculate SAAG)
# Amylase
# Neutrophil count
# Cytology
# Microscopy & culture
S.HBV-DNA by PCR
S.Iron Profile
S. alpha-fetoprotein
Liver Biopsy under USG control
S. Ammonia
Blood Urea
Electroencephalography (EEG)
33. TREATMENT
That Patient was referred to DMCH.
Following treatment was given when he was admitted in
our hospital-
1. Bed rest in horizontal position
2. Tab. Frusemide+Spironolactone (40/50 mg)
1+0+0
3. Tab. Teviral (0.5 mg)
0+0+1
4. Tab. Propranolol (40 mg)
1 +0+ 1
5. Syp. Lactulose
4 TSF ✖ thrice daily
6. Tab. NaCl
1+1+1
7. Cap. Multivitamin
0+0+1
34. ADVICE
Dietary Advice:
1. Avoid salt containing & salt retaining diets like as-
cheese,butter,tomato,peanut,pickle,olive etc.
2. Can intake fresh milk,yoghurt,eggs,legumes,chicken,
fish,fresh vegetables.
3. Drinking of water not more than 1.5 L/day.Replace tea
coffee or water with fluids that provide energy (such
as milk).
4. Stictly avoid any kind of NSAIDs,steroids & antacids.
Advice To His spouse :
To do HBsAg screening test as soon as possible.If the result is
negative,then get immunized by hepatitis-B vaccine.
Social Advice:
Never donate blood or share needle.All the family members
should be vaccinated by hepatitis-B vaccine.
35. FOLLOW UP
Daily Follow Up:
Monitor weight (wt loss
should be 0.5 to 1 kg/day)
Abdominal girth
Urinary output
Bowel movement
Orientation
Sleep rhythm
Flapping Tremor
Vital signs
Follow Up After 1
Month:
S. Bilirubin
S. Electrolytes
S. Total Protein
Prothrombin Time