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. 





Comments

Post a Comment

Popular posts from this blog

A69 YR OLD MALE WITH BILATERAL HYDROURETERO NEPHROSIS AND AKI ON CKD

Image
  THIS IS AN 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT . Name : Ankitha reddy Roll no : 67 CASE :  A 69 year old male who is farmer by occupation came to the opd with cheif complaints of : B/L pedal edema present since 15 days Burning micturation since 15days Increased frequency of micturition (10-15times per day ) and urgency  Nocturia 5-6 times  Itching all over the body since 7 days HISTORY OF PRESENTING ILLNESS:  Patient was apparently asymptomatic 15 days back and later he developed bilateral pedal which is pitting type of edema since 15 days and buring micturition . There is increased frequency of urination i.e; 10 to 15times per day and nocturia...
Read more

32 yr old male with fever and generalized weakness

Image
MEDICAL ONLINE BLENDED BIMONTHLY ASSIGNMENT(MAY-2021)  32 yr old male with fever and generalized weakness    This is an 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 patient's 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 the comment box NAME : Ankitha Reddy ROLL NO : 67 A 32yr old male who is a farmer by occupation was brought to casualty with  CHEIF COMPLAINTS :  FEVER since 1 week. HEADACHE since  5 days GENERALISED WEAKNESS AND JOINT PAINS HISTORY OF PRESENT ILLNESS:  Patient was apparently asymptomatic 1 week back. Then he developed fever which is moderate to high grade, intermittent ( o...
Read more

Internship Assessment

Name : Ankitha Roll no : 78 2017 Batch Period of Posting : 12/02/23 to 13/04/23 This blog is all about my learning experiences  in 2 months of my internship while i was posted in general medicine department. First i had Psychiatry posting for 15 days  During Psychiatry  postings : 1. I got to see numerous cases in the opd which includes schizophrenia , depression, alcohol dependence disorder , drug addiction , postpartum blues , anxiety , panic attacks . 2. I learnt to take history of such diverse cases and understood the importance of patient confiding in us and how it impacts our diagnosis and treatment. 3. I learnt to manage and monitored patients in delirium  4. I visited de-addiction centre and learned about the activities done there and treatment given for those patients. 5. I learnt to do mental status examination  Then i was posted in UNIT-6 in medicine department for 1month  OP AND UNIT duty experience: We had op days every Saturday and saw approxi...
Read more