CASE HISTORY

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CHIEF COMPLAINTS:-

A 36y/o man came to OPD with chief complaints of

1) Abdomen distension since 10 days

2) Scrotal swelling and pain since with Low urine output - 10 days

HISTORY OF PRESENT ILLNESS :

The patient was asymptomatic 8 months back then he developed abdominal distention and swelling at the scrotum which was on and off for which he came to the hospital and was treated for the same, after which the abdominal distention and swelling subsided for a few days.

In the meanwhile, he restarted his habit of smoking and alcohol consumption.

The abdominal distention and swelling of the scrotum reappeared 10 days back.

The distention of the abdomen is insidious in onset, and gradually progressing to present stage and uniformly distended

and not associated with pain.

The swelling of the scrotum is associated with pain and is of sudden onset, and nonprogressive.

The pain at the scrotum is of dragging type, and it aggravates on movement and gets relieved with medication.

The patient has low urine output with a decreased stream, he has no burning micturition and no fever.

He observed gradually progressive pedal oedema for 10 days.

HISTORY OF PAST ILLNESS:

The patient has had a history of similar complaints in the past 8 months.

The patient is a diabetic for 2years and is on medication for the same.

There is no history of hypertension.

No h/o epilepsy, tuberculosis.

The patient had undergone surgery for haemorrhoids 10 years ago.

PERSONAL HISTORY:

The patient has loss of appetite, 

-Has normal sleep.

-Has decreased urine output 

-He is often constipated.

-The patient is addicted to alcohol and smoking for 10 years.

He consumes 400-500ml of whisky per day which was sometimes increased to 750 ml per day .

He consumes 5-6 cigarettes per day which was sometimes increased to 10.

FAMILY HISTORY:

There is no significant family history .

TREATMENT HISTORY:

The patient is on medication for diabetes.

Has no history of any drug allergy.

GENERAL EXAMINATION:

The patient is conscious coherent and cooperative.

                -No pallor

                -No icterus

               -No cyanois

               -No clubbing of fingers and toes.

               -No lymphadenopathy

-               Bilateral pedal edema present.

VITALS:

              Temperature- afebrile,

               Pulse rate- 112 bpm

               Respiratory rate- 22 times per minute

               Blood pressure- 110/70 mm hg.

                                                 

        

                                                    

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

INSPECTION-

                -Chest wall is bilaterally symmetrical.

                - No visible pulsations , scars , sinuses, engorged veins.

                - No gross swelling or mass visible

                - No precordial bulge.

                - The carotid artery was prominent.

PALPATION-

                  - There are no tender points while palpation

                 -Apex beat was palpated at the left 6th intercostal space along the axillary line

                  -position of the trachea is central.

                 - no other mass or swelling is palpable.

AUSCULTATION- 

                             -S1, S2 heard.

                              -Apex beat is heard at the left 6th intercostal space along the axillary line.

 RESPIRATORY SYSTEM.

INSPECTION-

                        -Bilaterally symmetrical chest 

                        -No visible pulsations, scars, sinuses, engorged veins,

                        -Rate of respiration is 22 breaths per

                         -Movements of the chest wall are normal.

PALPATION-

                           - Position of the trachea is central

                            -Apex beat is palpable at the left 6th intercostal space along the axillary line.

                            -chest expansion is symmetrical on palpation

                            - vocal fremitus is bilaterally equal in intensity.

AUSCULTATION

                         - Bilateral movement is equal 

                         - Normal vesicular breath sounds heard

                         -Wheeze is heard on exhalation.

 GASTROINTESTINAL SYSTEM

PER ABDOMEN 

                  - abdomen is non-tender

                   - bowel and bladder sounds heard

                   - free fluid is present

Inspection - 

                     shape - generalised distension due to fluid

                     Umbilicus - inverted

                     No visible pulsations dilated veins.

                     No visible peristalsis

                    No striae or prominent superficial veins seen 

                    No IVC obstruction

Palpation - non-tender       

Percussion-shifting dullness and fluid thrill are demonstrated.

Auscultation - bowel sounds heard.

Provisional diagnosis: cardiomegaly and chronic liver disease secondary to alcoholism.

INVESTIGATIONS-

  

Final diagnosis: Heart failure with decompensated liver disease and hemi scrotal abscess 

Treatment : 

             Fluid and salt restriction

             Inj. Lasix IV/BD

             Inj. Tramadol (1amp in 100 ml NS) IV BD

            Inj. Vitamin K 10 mg IM OD

            Inj. Metrogyl 100 ml IV/TID

           Tab. Aldactone 50 mg PO/OD

           Tab. Carvidelol 3.125 mg PO/OD

           Tab thiamine 100 mg PO/OD

           Tab. Ultracet 1/2 PO/OD

           Tab. Udiliv 150 mg PO/BD

           Tab. Metformin 500 mg PO/OD

           Tab. Chymerol forte PO/TID

           Syp. Lactulose 15 ml PO/HS.