A 40 YR OLD MAN WITH SHORTNESS OF BREATH , JAUNDICE & REDUCED URINE OUTPUT

 A 40 yr old male patient came to the casualty with CHEIF COMPLAINTS of shortness of breath worsening since 2 hrs ( GRADE 3-4 ) , palpitations, bilateral pedal edema - pitting type since 10-15 days , Abdominal distension & decreased urine output since 15 days , history of fever 1 week back now it was subsided. 

HISTORY OF PRESENT ILLNESS: 

## Normal routine before this catastrophe , of this 40 year old gentle man was waking up at 6 am and eat food ( rice & curry ) — goes to do work related to agriculture (paddy field worker ) and daily wage worksby 8am — lunch ( rice & curry ) at 2/3 pm  — resume work — comes home by 5-6 pm in the evening— takes bath & have dinner ( rice & curry ) — goes with friends outside and have toddy and whiskey — comes home by 9pm . 

* He studied 10th class 

* He has mixed diet and his married life was 10 yrs , the interaction with the family( wife , two sons : one aged 8 yrs and other 1 1/2 yrs ) was good and he has adequate sleep . 

Patient was apparently asymptotic 6 months back ,

One day (6 months back) when he was lifting bricks ; he experienced shortness of breath for the first time and also he noticed some pedal edema 

— for which he visited local doctor and was releived of his symptoms and he was diagnosed to have LIVER FAILURE ? ,with yellowish discolouration of eyes and was advised medication , from then he had intermittent episodes of SOB on doing work and continued medication.

From 6 months his routine remained unchanged ( except he used to take rest and medication when there is an episode of SOB , on doing work ) and he stopped drinking alcohol with his friends , instead of that he spent some quality time with the family.

** But now on presentation ; he developed sever SOB ( grade 3-4 ) again on doing work in the field .

History of pedal edema, in both lower limbs since 10-15 days which is incidious in onset and gradual in progression and worsened to the present size. 

History of abdominal distension, since 10-15 days which is progressively increasing.

* Endoscopy was done and grade 1 varices are present and ultrasound showing mild splenomegaly.

History of decreased urine output since 10-15 days, with normal stream & post voidal residue with urgency and hesitency present.

## Now his routine changed to an extent that he can’t even walk properly with out developing SOB , so he stopped doing his agricultural and other works, now although he is waking up at 6 am ; he is taking rest , he is having decreased appetite & sleep was normal , family interactions are healthy. The financial needs now ( as he stopped working ) are met by the savings of the family .

PAST HISTORY:

* He is a known case of diabetes since 6 months and was on treatment 

* Not a known case of Hypertension, Asthma, TB, Epilepsy, Coronary Artery Disease.

* History of hemodialysis in outside hospital in the view of metabolic acidosis and decreased urine output.

PERSONAL HISTORY:

* Appetite: decreased 

Diet: mixed

Sleep : adequate 

Bowel and bladder movements: ## Regular bowel movements but, 

                 ## Has decreased micturition since 10-15 days 

Additions: * History of toddy intake since 16 years of age & whisky and brandy 90-180 ml since 10-12 years.

FAMILY HISTORY:

* Not significant

GENERAL EXAMINATION: 

Patient is conscious coherent and cooperative.

He is well oriented to time, place and person.

He is moderately built and well nourishedVITALS: 


Temperature: Afebril


Pulse Rate: 78 beats per minut


Blood pressure: 90/80 mm of HG


Respiratory Rate: 24 cycles per minut


SpO2: 94-96 % on room a


Pallor : present




Icterus : present (mild )



No Cyanosis

No Clubbing

No Lymphadenopathy

Edema : present 


SYSTEMIC EXAMINATION:

1) Abdominal examination: 


Inspection:


* Shape of the abdomen: distended 


* Umbilicus: slit shaped


* No visible pulsations


* Movements of abdominal quadrants with respiration are not appreciated .


* No visible scars.


Palaption:


* No local rise of temperature 


* No tenderness 


* No palpable masses found


* Liver and spleen are not palpable 


Percussion :


* Shifting dullness : present 


* Liver span: normal


Ascultation: 


* bowel sounds are heard.


2) Respiratory system: 


* Bilateral Air entry present


* Normal vesicular breath sounds are heard


* Position of trachea : central 


* No wheeze, no crepts


3) CVS: 


* S1 and S2 heart sounds are heard


*No murmurs 


4) CNS: 



* No abnormality detected  


INVESTIGATIONS :


RFT , LFT , HEMOGRAM , CUE , ECG , USG - Abdomen , BGT , ABG , VIRAL SEROLOGY , CHEST X RAY, 2D echo.














Fever chart :


ASCITIC TAP video link ;


**Ascitic fluid samples (One for culture and other for cell counts)

Interpretation of reports: 

Hemogram : Anemia & decreased platelet count 

USG : 1) LIVER - Coarse echo texture with irregular margins ( CLD ? , to be correlated with LFT’s )
2) Gall bladder wall thickened 
3) Bilateral Grade 1 RPD 
4) Moderate Ascitis

Serum protein : decreased 
Serum creatinine : elevated 
Blood urea : elevated 

LFT : Mild increase in bilirubin

ECG & CHEST X Ray : Normal 

2D echo : Dilated cardiac chambers with normal Ejection Fraction

DIAGNOSIS :

CHRONIC LIVER FAILURE  
HEPATO RENAL SYNDROME OR 
CHRONIC KIDNEY DISEASE ??

TREATMENT:
 
* Fluid restriction : < 1t / day
* Salt restriction : < 2gm / day
* Tab . Lasix - 40 mg , BD
* Tab . Metalazone 5mg , BD 
* Tab . Thiamine 100 mg , OD
* Syrup . Lactulose 15 ml , BD
* Tab . Rifagut 550 mg , BD
* Protein powder with 100 ml milk , 2 times daily 
* Abdominal girth & weight measurement daily
* Tab . Udiliv 300 mg , BD
* 2-3 egg whites / day


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