1801006195 - short case

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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 .

A 75year old male farmer by occupation came to the OPD with the CHIEF COMPLAINTS of

Abdominal distension since 1 month

Decrease appetite since 1 week

Decreased urine output since 1 week

Swelling of right lower limb since 2 days

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 2 months ago then he developed pain in the abdomen which was insidious in onset,  diffuse , intermittent non radiating. 

He then noticed Abdominal distension which was progressive associated with shortness of breath since yesterday which aggravated on lying down relieved on sitting   

C/o decreased urination frequency i.e, 2-3 times a day since 1week

H/o episode of vomiting, 2 days ago 1 episode, ,non projectile, non bilious , foul smelling , non blood stained, containing food particles

H/o pedal edema in right leg followed by left leg progressive and pitting type 

 H/o constipation since 1 month 

H/o reduced appetite since one week

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

No H/O fever, nausea, vomitings, loss of consciousness, pruritis 

PAST HISTORY: 1month back he developed similar complaints 

An ascitic fluid tap was done at which revealed high saag high protein with decreased sr. Amylase.

He was diagnosed with ascites secondary to decompensated liver disease, spontaneous bacterial peritonitis with Heart failure with preserved ejection fraction

Patient got treated and CT abdomen findings were suggestive of Hepatocellular carcinoma 

He was then referred to MNJ cancer hospital where liver biopsy was done which showed no malignancy & was asked for repeat biopsy .

Not a known case of DM, HTN, CAD, Asthma, Tuberculosis, Epilepsy.

No h/o previous blood transfusions

No h/o previous abdominal surgeries

FAMILY HISTORY: 

Not significant 

PERSONAL HISTORY :

Diet : mixed

Appetite: decreased

Sleep : disturbed

Bowel and bladder: decreased 

Addictions alcohoic - occasionally 

Non smoker

GENERAL EXAMINATION 

Patient 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 

Abdominal Examination

INSPECTION

Shape of abdomen -uniformly distended

Flanks -full

Umbilicus-central,horizontal slit

Skin -stretched,shiny,puncture mark present(ascitic tap),no scars,sinuses,straie 

No dilated veins

No visible peristalsis 

PALPATION 

no local rise of temperature 

tenderness present 

All the inspectory findings are confirmed.

Liver and spleen couldn't be palpable due to distension.

Measurements

-Abdominal girth : 97 cm

- Xiphisternum to umbilicus - 22 cms

-Public symphysis to umbilicus - 12cms

PERCUSSION 

Fluid thril negative

Shifting dullness present

AUSCULTATION 

Bowel sounds are heard

RESPIRATORY SYSTEM 

Bilateral air entry present

Normal vesicular breath sounds are heard

no added sounds

Cardiovascular system

S1 s2 heard

No murmurs

Central Nervous System 

Higher motor functions are intact

no focal neurological deficit

 PROVISIONAL DIAGNOSIS

ascites  

INVESTIGATIONS

Hb-8.6 gm/dl(13-17)

Total count-19,400cells/cu mm(4000-10,000)

Neutrophils -83(40-80)

Lymphocytes -1020-40)

PCV- 26%(40-50)

RBC count- 2.6millon/cu mm(4.5-5.5)

Serum creatinine -3.5mg/dl(0.8-1.3)

Blood urea-140mg/dl(17-50)

Electrolytes- 

Na 125

K 3.9

Cl 96

Ca 0.98

Complete Urine Examination

Normal

Liver Function Test - 

Total bilirubin -  11.58mg/ dl

Direct bilirubin - 9.45mg/dl

SGOT - 597 IU/L

SGPT -  117IU/L

ALP -  628IU/L

Total protein -  5.6gm/dl

Albumin - 2.23g/dl

A/G ratio 0.66

Serology- 

HbsAg negative

Ultrasound- 

Irregular and nodular border of the liver with altered echotexture

Hepatomegaly

Gross ascites 

Chest xray

Ultrasound- 

Gross ascites 

ECG

ASCITIC FLUID ANALYSIS 

Results-

LDH - 153 IU/L - decreased

Protein - 1.4 g/dl

Sugar- 73 mg/dl

Protein sugar within normal limits

Ascitic albumin - 0.67 g/dl

SAAG - high

Ascitic fluid Amylase- 31.7IU/L

Total count - 550 cells

Differential count 

Neutrophils- 98%

Lymphocytes

FINAL DIAGNOSIS- 

ASCITES SECONDARY TO DECOMPENSATED LIVER DISEASE 

TREATMENT :

1. IV fluids NS at 30 ml/hr 

2. Inj. Lasix 40mg iv/bd 

3. Fluid restriction <2L/day

4.  Salt restriction <1.2g/ day

5.  Syrup lactulose 30ml po/bd 

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

7. Inj. Cefotaxime 2gm Iv/tid

8. BP ,PR monitoring every 4 th hourly

9. Abdominal girth and weight monitoring.