65 year old male with Ascitis secondary to decompensated liver disease

M VARUN SAI ( INTERN)

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.
All quadrants of abdomen moving equally with respiration.
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.



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