48 year old male with abdominal distension since 2 months,bilateral pedal edema since 2 months

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan

Chief complaints

48 year male cab driver by occupation resident of west Bengal came to general medicine OPD with C/O abdominal distension since 2 months,B/L pedal edema since 2 months,decreased appetite since 2 months,decreased urinary output since 1 month 

HOPI -Patient was apparently asymptomatic 2months back then he developed abdominal distension ,insidious onset gradually progressive associated with decrease in appetite since then B/L pedal edema up to knee since 2 months,pitting type increased on walking releived with rest,decreased urinary output since1 month ,insidious onset gradually progressive. 

No h/O fever,cough,breathlessness

No H/O DM,HTN, TB, Epilepsy, seizures, CVA CAD

Personal history 

Appetite-Normal

Diet-Mixed

Bowels and bladder-Regular 

Micturition-Normal 

Addictions-180 ml --

Family history-Not significant 

General examination 

Patient is conscious coherent cooperative well oriented to time, place and person.

moderately built and nourished.

Pallor-absent

Icterus -absent

Cyanosis-absent

Clubbing-absent

Generalised Lymphadenopathy-absent

Edema-bilateral pedal edema present

VITALS:

Temperature - 98.2F

PR :- 95bpm

RR : 22cpm

BP :- 110/70mm Hg

SPO2 :- 98%@RA

GRBS :- 110mg/dl.

SYSTEMIC EXAMINATION 

Per abdomen - 

Abdominal girth- 93-->91cm

Inspection- 

Abdomen is distended , flanks are full, skin is stretched , no visible peristalsis , equal symmetrical movements in all quadrant’s with respiration 

Palpation - 

No local rise of temperature, no tenderness

All inspectory findings are confirmed by palpation, no rebound tenderness, gaurding and rigidity.

No tenderness , No organomegaly 

Fluid thrill present 

Percussion:

Shifting dullness present 

Auscultation:

Bowel sounds heard 

CVS : S1 and S2 heart sounds heard

CNS: NO focal neurological deficits 

RR: BAE Present, normal vesicular breath sounds heard,no adventitious sounds

shape of the chest: normal

trachea appears to be central

Ascitic tap 

https://youtube.com/shorts/64TvtPabem4?si=FHtF1jW8Ba-8e5yH

PHES test

INVESTIGATIONS 

Ascitic tap - 

Appearance - clear , yellow coloured 

SAAG - 1.65 g/dl

Serum albumin - 2.0 g/dl

Asctic albumin - 0.35 g/dl

Ascitic fluid sugar - 104mg/dl

Ascitic fluid protein - 0.7 g/dl

Ascitic fluid amylase - 17 IU /L

LDH : 143 IU/L 

Cell count- 50 cells 

Lymphocytes nil

Neutrophils 100%.

TREATMENT :

Tab LASIX 40 mg PO BD

Syp. Lactulose 10 ml PO HS

Strict Alcohol abstinence .