75yr male with ascites secondary to degenerative liver disease

K.Ankitha

Rollno : 78

This is online E log book to discuss our patient’s de-identified health data shared after taking   his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .

 

I’ve 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 . 

CHIEF COMPLAINTS :

C/O abdominal distension since 1 week

C/O decrease appetite since 1 week

C/O decreased urine output since afternoon

HOPI :

Pt was apparently asymptomatic 1 month ago then he developed pain in the abdomen which was diffuse , intermittent. Then he noticed abdominal distension since 1 week , insidious in onset , gradually progressive to the present size , 

History of decreased appetite since 1 week 

No H/O fever , loose stools , vomitings and constipation .

He complained of decrease in urine output since afternoon .

PAST HISTORY :

No similar complaints in the past.

N/K/C/O DM , HTN , ASTHMA , TB , CAD , CVA , Thyroid disorders.

No H/O alcohol intake and smoking.

GENERAL EXAMINATION :

Pt is conscious , coherent , cooperative 

Moderately built and nourished .

No signs of pallor , icterus , cyanosis , clubbing , lymphadenopathy .

Pedal edema present .

VITALS :

Afebrile.

PR - 120bpm

BP - 130/80 mmhg

RR - 20 cpm

SpO2 - 98% on Room air

GRBS - 102mg%

SYSTEMIC EXAMINATION :

CVS - S1S2 heard , no murmurs.

RS - BAE present , no added sounds.

CNS - HMF intact , NFND 

P/A - 

INSPECTION - 

Abdomen distended with flanks full. umbilicus central 

No scars and sinuses.

No engorged veins.

PALPATION -

no local rise of temperature 

No tenderness 

All the inspectory findings are confirmed.

Liver and spleen couldnot be palpable due to distension.

PERCUSSION-

Fluid thrill negative 

Shifting dullness present .

AUSCULTATION -

bowels sounds are heard.

Abdominal girth - 97cms

Weight - 65kgs

            APRAXIA CHARTING

DIAGNOSIS -

ASCITIS UNDER EVALUATION.

INVESTIGATIONS :

        ASCITIC FLUID TAP WAS DONE

         

                Ascitic fluid analysis

USG ABDOMEN AND PELVIS

DIAGNOSIS:

ASCITIS SECONDARY TO DECOMPENSATED LIVER DISEASE 

?SPONTANEOUS BACTERIAL PERITONITIS ( TLC 1200 with 98% neutrophils)

HEART FAILURE WITH PRESERVED EJECTION FRACTION (EF - 58%)

TREATMENT :

1. IV fluids at 75 ml/hr 

2. Inj. Lasix 40mg iv/bd 

3. Inj.optineuron 1 ampule in 100ml NS iv/od

4. O2 inhalation to maintain saturation >94%

5. Nebulization with ipravent 6th hrly , budecort 12th hrly

6. Inj. Cefotaxime 2gm iv/tid

7. Inj. Vitamin k 10mg iv/od

8. Syp.sucralfate po/hs

9. Abdominal girth and weight monitoring.

PRESENT CASE HISTORY (18/03/23)

CHEIF COMPLAINTS :

Abdominal distension since 1month

Decreased appetite - 1 week

Deceased urine output since 3weeks 

Swelling of right lower limb since 2days 

HISTORY OF PRESENT ILLNESS :

Patient was apparently alright 2 months

back then he developed pain abdomen on and off , then he developed abdominal distension , insidious in onset, gradually progressive .

Patient is a k/c/o Ascitis secondary to Decompensated liver disease (High SAAG High protein) spontaneous bacterial peritonits with HFPEF , AKI 

Patient got treated and ct abdomen findings were suggestive of Hepatocellular carcinoma  & he was referred to mnj where liver biopsy

was done which showed no malignancy & was asked for repeat biopsy .

Patient now again, presented with abdominal distension & decreased urine Output

H/O episode of vomiting, yesterday evening, containing food particles

No H/o loose stools

H/o constipation since 1 month 

H/O weight loss present (5-6 kgs in 2 months )

HISTORY OF PAST ILLNESS

Not a k/c/o DM , HTN, CAD,CVA, epilepsy, TB , thyroid disorder 

GENERAL EXAMINATION :

Pt is conscious , coherent , cooperative 

Moderately built and nourished .

No signs of pallor , icterus , cyanosis , clubbing , lymphadenopathy , edema 

VITALS :

Afebrile.

PR - 90bpm

BP - 130/80 mmhg

RR - 20 cpm

SpO2 - 98% on Room air

GRBS - 106mg%

SYSTEMIC EXAMINATION :

CVS - S1S2 heard , no murmurs.

RS - BAE present , no added sounds.

CNS - HMF intact , NFND  

P/A - 

INSPECTION - 

Abdomen distented , umbilicus central

No scars and sinuses.

No engorged veins.

PALPATION -

No local rise of temperature 

tenderness present

All the inspectory findings are confirmed.

PERCUSSION-

Fluid thrill negative 

Shifting dullness present .

AUSCULTATION -

bowels sounds are heard.

ASCITIC FLUID TAP WAS DONE 

Ascitic fluid sample investigations :

INVESTIGATIONS : 

Usg abdomen :

PROVISIONAL DIAGNOSIS :

Ascites secondary to degenerated liver disease,Heart failure with preserved ejection fraction (58%) ,acute kidney injury (renal)

TREATMENT :

1. IV fluids NS at 30 ml/hr 

2. Inj. Lasix 40mg iv/bd 

3. FLUID RESTRICTION <2L /DAY

4. SALT RESTRICTION <1.2 GM/DAY

5. INJ. CEFOTAXIME 2GM IV/TID

6. Syp.LACTULOSE 30ml po/bd.