56F with abdominal distension since 20 days

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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


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