50 yrs old male with abdominal distension

This is an online E logbook to discuss our patients' 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 the available global online community of experts intending to solve those patients clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome. 

Name: G Sai Manogna

Hall ticket No: 1701006046

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 a diagnosis and treatment plan.

Following is the view of my case :

CASE PRESENTATION:

A 50 years old male who is a farmer by occupation, resident of pochampally has presented to the casualty  on 02 June 2022 with the chief complaints of

• Abdominal distension since 8 days
• Pain in the abdomen since 8 days
• Pedal edema since 6 days

History of presenting illness:

Patient was apparently asymptomatic 6 months ago when he developed jaundice and was treated in  a private hospital

Then he developed abdominal distension 8 days ago which was insidious in onset and gradually progressive to the present size

There were no aggravating and relieving factors

His last consumption of alcohol was on 29th May 2022

It was associated with pain abdomen in the epigastric and right hypochondriac region which is insidious in onset and diffuse to whole of the abdomen and gradually increased in intensity and is of colicky type

Pain is persistent throughout the day. No history of radiation to the back.

No complaints of fever, nausea and vomiting

There were no aggravating and relieving factors

It was associated with bilateral pedal edema below knees and is of pitting type, which was insidious in onset and gradually progressive throughout the day and is maximum in the evening and is not relieved by rest

No local rise of temperature and tenderness

Associated symptoms- shortness of breath since 4 days

There is no history of orthopnoea, PND or palpitations

No history of facial puffiness and haematuria

No history of evening rise of temperature, cough, night sweats

No history suggestive of hemetemesis, melena, bleeding per rectum 

No raised JVP, basal lung crepitations

No palpable mass per abdomen

Daily routine

Patient usually wakes up at 5 am and goes to field and comes home at 8 am and has rice for breakfast and returns to work at 9 am

At 1 pm he will have his lunch

Then he goes to work from 2 pm to 6 pm and at 6 pm he comes to home 

At 8 pm he will have his dinner and at 9:30 pm he goes to sleep

Past history

No history of similar complaints in the past

Not a known case of Hypertension, Diabetes, asthma, epilepsy, TB

No previous surgical history

Personal history

Diet- Mixed

Appetite- Decreased since 10 days

Bowel and bladder movements- Urine frequency is reduced since 3 days and patient has an history of constipation

Sleep- Adequate

Addictions-

Patient is a chronic smoker since 30 years- 4to5 beedis/day

Alcohol - Consuming whisky since 20 years- 3 to 4 times per week (90 ml each time), but stopped consuming regularly 6 months back

Patient consumes toddy occasionally

No history of drug or food allergies

Family history

No similar complaints in the family

General examination

Done after obtaining consent, in the presence of attendant with adequate exposure

Patient is conscious, coherent, cooperative and well oriented to time, place and person

Patient is well nourished and moderately built

 

Icterus is positive

Pedal edema- present- bilateral pitting type

No history of pallor, cyanosis, clubbing and lymphadenopathy

Vitals

Temperature- Afebrile

Blood pressure- 120/80 mm of Hg

Pulse rate- 78 bpm

Respiratory rate- 16 cpm

EXAMINATION OF HANDS AND ARMS :

Tremors were present. 

Local examination

Abdominal examination:

Inspection

Shape of the abdomen- Distended

Umbilicus- everted

Movements of abdominal wall- moves with respiration

Skin is smooth, shiny

No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites

Palpation

Inspectory findings are confirmed

Tenderness is present in whole of the abdomen

Guarding and rigidity present

Fluid thrill positive

No hepatosplenomegaly

Abdominal girth at the level of umbilicus is maximum

Percussion

Tympanic note is heard on the midline and dull note is heard on the flanks in supine position

Fluid thrill- felt 

Liver span- Not detectable

Auscultation

Bowel sounds are decreased

Cardiovascular system examination:

S1 and S2 sounds are heard

No murmurs

Respiratory system examination:

Bilateral air entry present

Normal vesicular breath sounds are heard

Central nervous system examination:

No focal neurological deficits

Investigations:

Serology

HIV- Negative

HCV- Negative

HbsAg- Negative

Hemogram

Haemoglobin- 9.8 gm/dl

Total count- 7200 cells/cumm

Neutrophils- 49%

Lymphocyes- 40%

Eosinophils- 1%

Monocytes- 10%

PCV- 27.4 vol%

MCH- 33 pg

MCHC- 35.8%

RDW- 17.6

RBC count- 2.97 millions/cumm

Prothrombin time

Prothrombin time- 16 sec

INR- 1.11

ECG

Colour doppler

Ascitic fluid cytology report

Bacterial culture & sensitivity report

Ascitic fluid protein sugar

Sugar- 95 mg/dl

Protein- 0.6 g/dl

Ascitic fluid for LDH

LDH- 29.3 IU/L

Blood Urea

Blood urea- 12mg/dl

ESR

ESR- 15mm/1st hour

LFT

Total bilirubin- 2.22 mg/dl

Direct bilirubin- 1.13 mg/dl

SGOT(AST)- 147 IU/L

SGPT(ALT)- 48 IU/L

Alkaline phosphate- 204 IU/L

Total proteins- 6.3 gm/dl

Albumin- 3 gm/dl

Serum electrolytes

Sodium- 133 mEq/L

Potassium- 3 mEq/L

Chloride- 94 mEq/L

Serum creatinine

Serum creatinine- 0.8 mg/dl

APTT

APTT test- 32 sec

SAAG

Serum albumin- 3 gm/dl

Ascitic albumin- 0.34 gm/dl

SAAG- 2.66

Ultrasound

Chest Xray

Provisional diagnosis:

Decompensated chronic liver disease with ascites

Treatment:

1. Inj PAN 40 mg IV/OD

2. Inj LASIX 40mg IV/BD

3. Tab Spiranolactone 50mg/ BD

4. Inj Thiamine 1 amp in 100 ml NS IV/ TID

5. Syrup lactulose 15 ml/ TID

6. Abdominal girth charting 4th hourly

7. Fluid restriction <1L/ day

8. Salt restriction <2g/ day

Ascitic fluid tapping

Ascitic fluid was tapped twice- on 2nd June 2022 & 6th June 2022