56F with abdominal distension since 20 days

Hi!! This is Vijaya ratna,9th semester medical student. This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is 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, investigations and come up with diagnosis and treatment plan

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

A 56 year old female presented to General medicine department with C/o

Abdominal distension since 20 days

Pedal edema upto knees since five days

HISTORY OF PRESENTING ILLNESS

Patient  was apparently asymptomatic 20 days ago then she developed abdominal distension, which was insidious in onset, gradually progressive in nature

Abdominal Fullness present aggravated after having food

Patient has pedal edema since five days- on and-off which is continuous,pitting type, upto knee level 

Patient complains of SOB when abdominal bloating is present

No c/o chestpain, palpitations ,orthopnea, PND

No fever, cough, cold, vomitings ,loosestool

PAST HISTORY:

She is a k/c/o chronic liver disease since 1 year

Pt was admitted with similar complaints 11 months back and therapeutic ascitic tap was done

K/c/o HTN since 13 years on tab Telma 40 MG PO/OD

K/c/o Hypothyroidism since13 years on tab.thyronorm PO/OD

K/c/o DM type 2 since 4 yrs on metformin 500mg PO/OD

Not a k/c/o asthma,CVA,CAD,TB,epilepsy

PERSONAL HISTORY:

Diet-mixed

Appetite:normal 

Bladder movements -regular

Bowel-Has constipation 

Addictions-beetelnut(pan) since 30yrs

Sleep -adequate

GENERAL EXAMINATION:

Patient was consious, coherent and co-operative

Moderately built and nourished 

No signs of pallor,icterus,cyanosis,clubbing and lymphadenopathy

B/L pedal edema-present (upto knee level-pitting)

Vitals: 

Temp: afebrile

Bp: 100/70 mmHg

PR: 72bpm

RR: 20 cpm

SpO2: 98% on RA

Systemic Examination -

ABDOMEN :

Abdomen - distended 

Normal hernial orifices 

Fluid thrill + 

Dilated veins absent

No tenderness 

No palpable mass 

No organomegaly 

No bruit heard

CVS 

S1 S2 + ,No murmurs

RESPIRATORY SYSTEM;

B/l symmetrical chest

Trachea - Central

B/l air entry present

NVBS heard

CNS:NFND

INVESTIGATIONS

2D echo

MRI ABDOMEN AND PELVIS

USG ABDOMEN AND PELVIS

USG ON 6/7/23 after Ascitic tap

Ascitic fluid sugar:187mg/dl

Ascitic fluid Protien:1.5gm/dl

Ascitic fluid for LDH:710 IU/L

Cell count of Ascitic fluid:

Total cells:100cwlls/cumm 

Neutrophils:nil

Lymphocytes:100%

LFT:

Total bilurubin:3.65mg/dl

Direct bilurubin: 1.51mg/dl

SGOT: 179IU/L

SGPT: 152IU/L

Alkaline phosphate:190 IU/L

Total proteins:5.2gm/dl

Albumin: 2.84g/dl

Fasting blood sugar: 112mg/dl

Hemogram:

Hb:15.2gm/dl

TLC:10200cells/cumm

Neutrophils 86%

Lymphocytes 8%

Eosinophils 2%

MCV-89.5fl

MCH-31.3pg

MCHC-34.9%

RBC count:4.87millions/cumm

Platelets:2.39lakh/cumm 

PROVISIONAL DIAGNOSIS:

Decompensated chronic liver disease ?NAFLD with k/c/o HTN and hypothyroidism since 13yrs

K/c/o DM-II since 3 yrs

HCV positive

TREATMENT

Fluid restriction <1L per day

salt restriction <2g/day

Tab.lasilactone 20/5mg PO/OD 

Syp.lactulose 10ml PO/TID 

Tab.telma 40mg PO/OD

Tab.metformin 500mg PO/OD

Tab.thyronorm 25mcg PO/OD

high Protein diet -2 egg whites/day

strict I/O charting

weight and abdominal girth monitoring 

monitor vitals and inform sos

Ascitic tap was done and about 600ml of fluid was removed 

Pre procedure vitals:BP-100/50mmhg PR:92bpm

Post procedure:BP-120/80mmhg PR:86bpm

ADVICE AT DISCHARGE:

Fluid restriction <1L per day

salt restriction <2g/day

Tab.telma 40mg PO/OD continue

Tab.metformin 500mg PO/OD continue at 8am

Tab.thyronorm 25mcg PO/OD continue at 8am

Tab lasilactone 20mg PO/OD x1 week at 8am

Syrup.lactulose 10ml PO/TIDx1 week 8am,1pm,8pm

high Protein diet -2gm/day