60 year old male with complaints of abdominal distension, bilateral lower limb swelling and dark stools



 A 60 year old male came to the casualty with the chief complaints of distension of abdomen since 2-3 months, bilateral lower limb swelling since 1 month and dark stools since 4 days. 


Patient was apparently normal 11 years back following which he developed sudden onset of chest pain associated with sweating and diagnosed with ? CAD and had CAG + PTCA and was on regular follow up since then.

 4 months later he had persistent headache and neck pain for which he was taken to the hospital nearby where he was diagnosed with HTN and Diabetes and treated accordingly. 

3 months back patient noticed progressive abdominal distension associated with SOB grade 3 for which he consulted the local RMP and got treated but refused to get admitted in hospital as he had to attend his daughter’s marriage in the coming week. Exactly one day after his daughter’s wedding patient had a bout of vomiting with fresh blood as content.

On Tuesday patient came to KIMS - NKP Gastro OPD, endoscopy was done which reveals grade 2-3 esophageal varices then he was immediately referred to KIMS - KHL for banding. Patient got admitted in KHL and banding was done. 

X RAY shows right sided massive effusion for which ICD was placed, large volume paracentesis done, 3L ascitic fluid recovered. 

INJ. Albumin and ocreotide was given.


K/c/o DM and HTN 

K/c/o CAD S/P PTCA 

Personal history - Consumes mixed diet, appetite lost, regular bowel movements 

Smoking history of 5-6 years and stopped 6 months back 


No significant family history 


Patient is conscious, coherent and cooperative 

Pallor and edema + 

Bp 110/90 mmhg 

Pr 80bpm 

Rr 17cpm 

Spo2 95%@ room air 

Grbs 103 mg/dl


CVS - s1 s2 + 

No murmurs 

RS - bae + NVBS

CNS - no FND

P/A - soft, non tender and distended abdomen


Provisional Diagnosis- Chronic Liver Disease with Portal Hypertension

Massive pleural effusion, ICD placed 


Investigations - 


Pleural fluid (KHL) - no organism, AFB -, protein 1.4, sugar 131, Ada - 13, cytology - reactive effusion 

PT 20 s

INR 1.4 

APTT 37s 

HB 7.7 

TLC 5300

PLT 1.10 L 

Na 141

K 3

Cl 101 

S. Creat 0.9 

Urea 21


USG- 1. Altered echo texture with irregular surface of liver f/s/o chronic liver disease 

  1. Cholelithiasis
  2. Diffuse subcutaneous edema noted in the abdominal wall 


Treatment - 

  1. TAB. LASIX 40 mg BD 
  2. TAB ALDACTONE 50 mg OD
  3. TAB PAN 40 mg PO OD 
  4. FLUID AND SALT RESTRICTION
  5. SYP. POTKLOR 10ml PO BD 
  6. INJ. HAI S/C acc to grbs charting 
  7. BP/PR/ TEMP CHARTING 4th HOURLY 
  8. DAILY BODY WEIGHT AND ABDOMINAL GIRTH MONITORING 
  9. GRBS MONITORING TID 
  10. ICD CARE 
  11. PROTEIN X POWDER 2 SCOOPS IN 100 ML MILK BD 
X RAY 


ECG 



CLINICAL IMAGES 










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