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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