Ascites secondary to chronic liver disease.

 THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT .

This E blog also reflects my patient-centered online learning portfolio and your valuable input in the comment box are welcome.

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, and investigations, and coming up with diagnosis and treatment plan

The patient/attender was informed of the purpose of the information being acquired. Informed consent was taken from the patient/attender and there is the omission of information that was requested to be omitted.

M.Vivek

2019

Roll no.82

DEMOGRAPHICS:

Age: 39 yrs

Gender: Male

Occupation: Cab driver

Address: West Bengal


CHIEF COMPLAINTS:

 A 39-year-old male came with chief complaints of:           

  • Abdominal distention since 2 months
  • Bilateral pedal edema since 2 months
  • Decreased appetite since 2 months
  • Decreased urine output since 1 month

HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic 2 months back. Then he developed abdominal distention which was insidious in onset, gradually progressive, and associated with decreased appetite.

Bilateral pedal edema extending up to knee since 2 months, pitting type, increased on walking and relieved with rest.

Decreased urinary output since 1 month 

No h/o fever, cough, breathlessness

No h/o pruritus, blood in vomiting and stools 







29/11/23




PAST HISTORY :


No h/o DM HTN TB asthma epilepsy CVA CAD.



PERSONAL HISTORY :-

Mixed diet 

Appetite -decreased 

sleep -adequate 

Bowel and bladder regular 

Consumes alcohol  180ml

stopped consumption of alcohol from the day of admission 

Smokes beedi 1 pack per day and stopped 3 months back


Daily routine. 

Patient  wakes up at 5:00am approx and freshen ups goes to his work place by cycling and have a cup of tea then at around 9 am has his breakfast (rice and dal) then he will have his lunch at 1:00 and then comes back home around 9:00 pm and  have dinner .consumes alcohol and goes to bed at 10:00pm

Alcohol comsumption alternative days


GENERAL PHYSICAL EXAMINATION:

Patient is conscious ,coherent and cooperative and 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 ,pitting type 









VITALS:

Temperature - afebrile 

PR :- 95bpm

RR : 22cpm

BP :- 110/70mm Hg




SYSTEMIC EXAMINATION 

Per abdomen - 


Inspection-

abdominal girth -

Abdomen is distended , flanks are full, skin is stretched  ,umbilicus is everted , no visible peristalsis , equal symmetrical movements in all quadrant’s with respiration , dilated abdominal veins are seen 

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 — dull note is heard from the level of umbilicus 

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 fluid



Chest x-ray 





USG abdomen 

PHES test




Interpretation:- 












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%.


29/11/23

Ward-9

Admission date- 16-11-23


S-No fever spikes 

   no stools passed 

    increased cough in the night - leading to inadequate sleep in the night 


     


O- Patient is consious ,coherent,cooperative 

     Pallor- present

   

  Icterus,cyanosis,lymphadenopathy  

clubbing -absent , pedal edema with pitting present 


Vitals-

BP-120/60mmhg

   

PR-82bpm 

RR-16cpm

Temperature-afebrile

CVS-S1 &S2 heard,no murmurs

RS-BAE+ ,NVBS

P/A-Distended, abdominal girth - 83cm -weight-46kg

CNS-No focal neurological deficits 


A- Ascites secondary to chronic liver disease 


P- Tab Lasik 40mg 

     Syrup lactulose 15ml

     Strict alcohol abstinence 

    monitor vitals


TREATMENT :

Tab LASIX 40 mg PO BD

Syp. Lactulose 10 ml  PO HS

Strict Alcohol abstinence .



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THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT . CHEIF COMPLAINTS:   Drowsy ; Anuria ( since 3 days ) ; generalized weakness (since 15 days )  HISTORY OF PRESENTING ILLNESS :  Patient was apparently asymptomatic 5 years back then he developed lower back pain then treated conservatively . But since 15 days pt developed generalized weaknesses while working in the farm. Then 3 days back patient developed anuria. H/O PAST ILLNESS:- No similar complaints of anuria in the past. But had complaints of generalized weakness since 2 years. PERSONAL HISTORY:- Diet:- Mixed Appetite:- Normal Bowel movements:- Normal Bladder:- Decreased urine output ADICTIONS:- Alcohol:
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