35M DCLD ; ACD ; DM

 Case History and Clinical Findings

PATIENT CAME WITH C/O DISTENSION OF ABDOMEN SINCE 3 MONTHS

C/O SHORTNESS OF BREATH SINCE 3 MONTHS

C/O PEDAL EDEMA SINCE 20 DAYS

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 3MONTHS BACK THEN DEVELOPED DISTENSION OF ABDOMEN WITH SHORTNESS OF BREATH , GRADE II , INSIDIOUS IN ONSET , GRADUALLY PROGRESSIVE , NO AGGREVATING AND RELIEVING FACTORS .

C/O PEDAL EDEMA SINCE 20 DAYS, B/L PITTING TYPE , EXTENDING UPTO THE KNEE

C/O DECREASED IN URINE OUTPUT SINCE 20 DAYS

C/O FEVER SINCE 5 DAYS ON AND OFF, ASSOCIATED WITH CHILLS AND RIGORSNO C/O ORTHOPNEA ,PND , CHEST PAIN

NO C/O ORTHOPNEA , PND, CHESTPAIN ,PALPITATIONS

NO C/O PAIN ABDOMEN , VOMITINGS ,LOOSE STOOLS

PAST HISTORY:
K/C/O CLD
K/C/O T2DM SINCE 6 MONTHS AND IS ON UNKNOWN MEDICATION
H/O ALBUMIN TRASFUSION DONE
N/K/C/O HTN, EPILEPSY, ASTHMA, THYROID DISORDERS

PERSONAL HISTORY :
DIET :MIXED
APPETITE :DECREASED
SLEEP: DISTURBED
H/O ALCOHOL INTAKE SINCE 20 YEARS EVERY DAY ABOUT -50ML
NO H/O TOBACCO INTAKE
NO H/O ALLERGIES

FAMILY HISTORY :
N/K/C/O DM, HTN ,EPILEPSY, ASTHMA , THYROID DISODERS .
GENERAL EXAMINATION :
PATIENT IS CONCIOUS, COHERENT AND COOPERATIVE , WELL ORIENTED TO TIME , PLACE AND PERSON
PALLOR : +
EDEMA PRESENT EXTENDING UPTILL THE KNEE
NO ICTERUS , CYANOSIS, CLUBBING , LYMPHADENOPATHY

VITALS :
TEMPERATURE :98.2F
BP: 120/80 MM/HG
PR: 84 BPM
SPO2: 99%
GRBS : 198 MG%
RR: 16CPM
SYSTEMIC EXAMINATION :
CVS: S1, S2 + , NO MURMURS
RS:BAE+,NO ADDED SOUNDS
CNS: NAD
PER ABDOMEN :
INSPECTION :
ABDOMEN - DISTENDED

UMBILICUS - CENTRAL
SCARS +,SINUSES

PALPATION :
TENDERNESS IN THE PERIUMBILICAL REGION
NO HEPATOMEGALY
NO SPLEENOMEGALY
HERNIAL ORIFICE - NORMAL
FREE FLUID - YES

PERCUSSION :
DULL NOTE ALL OVER THE ABDOMEN

AUSCULTATION :
BOWEL SOUNDS+

COURSE IN HOSPITAL:
PATIENT IS ADMITED I/V/O C/O DISTENSION OF ABDOMEN SINCE 3 MONTHS ,C/O SHORTNESS OF BREATH SINCE 3 MONTHS
AND C/O PEDAL EDEMA SINCE 20 DAYS AND WAS DIAGNOSED TO HAVE DECOMPENSATED CHRONIC LIVER DISEASE WITH GROSS ASCITIS WITH B/L PLEURAL EFFUSION ( MODERATE ) WITH K/C/O TYPE 2 DM SINCE 5 MONTHS .
PATIENT VITALS AT TIME OF ADMISSION :
TEMPERATURE :98.2F
BP: 120/80 MM/HG
PR: 84 BPM
SPO2: 99%
GRBS : 198 MG%
RR: 16CPM
BOTH DIAGNOSTIC AND THERAPEUTIC PARACENTESIS HAS BEEN DONE ON 28/7/23 AND 1L OF ASCITIC FLUID IS BEING REMOVED . AND ON ASCITIC FLUID ANALYSIS - HIGH SAAG ,LOW PROTEIN WAS FOUND .
PSYCHIATRY REFERRAL IS BEING KEPT ON 29/7/23 I/V/O ALCOHOL DEPENDANCE SYNDROME AND ADVISED - TAB. BACLOFEN XL 20MG PO OD AND CONTINUE THIAMINE SUPPLEMENTATION .
DIAGNOSTIC PLEURAL TAP BEING DONE ON 29/7/23 AND THERAPEUTIC PLEURAL TAP DONE ON 31/7/23 - 700ML OF PLEURAL FLUID BEING REMOVED .
GASTRO REFEERAL WAS TAKEN ON 1/8/23 AND ADVISED LARG3 VOLUME PARACENTESIS WITH ALBUMIN INFUSION .
ASCITIC TAP DONE ON 2/8/23 AROUND 1.8 L ASCITIC FLUID IS BEING REMOVED .
PATIENT IS BEING TREATED CONSERVATIVELY AND DISCHARGED IN HEAMODYNAMICALLY STABLE CONDITION .

VITALS :
TEMPERATURE-97F
BP- 110/70 MMHG
PR-88 BPM
RR-16 CPM

Provisional Diagnosis:-
DECOMPENSATED CHRONIC LIVER DISEASE WITH GROSS ASCITIS WITH B/L PLEURAL EFFUSION ( MODERATE , TRANSUDATIVE ) , ANEMIA OF CHRONIC DISEASE WITH K/C/O TYPE 2 DM SINCE 5 MONTHS

Investigation:-

HEMOGRAM :
Hb - 7.7
PCV- 22.3
TLC - 5,000
RBC COUNT - 2.36
PLATELET COUNT - 98,000
RBS - 194 MG/DL
BLOOOD UREA - 14
S. CREATININE - 0.7
S. NA + : 126
S. K+ :3.3
S.CL : 97

LFT:
T. BILIRUBIN - 1.75
D.BILIRUBIN -0.41
SGPT -11
SGOT- 27
ALKALINE PHOSPHATE : 161
T. PROTEINS - 5.7
ALBUMIN : 3.8

CUE :
COLOUR -PALE YELLOW
RBC - NIL
PUS CELL S- 3-4
SEROLOGY - NEGATIVE

04/08/23
HEMOGRAM :
Hb - 7.3
PCV- 21.2
TLC - 7500
RBC COUNT - 2.20
PLATELET COUNT - 1,30,000
SERUM ELECROLYTES
S. NA + : 132
S. K+ : 4.2
S.CL : 91

LFT:
T. BILIRUBIN - 1.95
D.BILIRUBIN -0.65
SGPT -11
SGOT- 30
ALKALINE PHOSPHATE : 172
T. PROTEINS - 5.6
ALBUMIN : 2.49
ASCITIC FLUID ANALYSIS :
ASCITIC FLUID SUGAR- 215 MG/DL
ASCITIC FLUID PROTEIN - 1.7 G/DL
SAAG- 2.96
ASCITIC FLUID LDH - 87.6 IU/L
ASCITIC FLUID AMYLASE - 3.7 IU/L
PLEURAL FLUID ANALYSIS:
PLEURAL FLUID ADA - 21U/L
PLEURAL FLUID SUGAR- 187 MG/DL
PLEURAL FLUID PROTEIN - 1.6 G/DL
PLEURAL FLUID LDH- 156
UGIE - SHOWN DIALATED ESOPHAGEAL VEINS

Treatment Given:-
1. FLUID RESTRICTION <2L/DAY
2. SALT RESTRICTION <2 GM /DAY
3.INJ. OPTINEURON 1 AMPULE IN 100ML NS IV OD AT 2PM
4. INJ. THIAMINE 200MG IN 100 ML NS IV OD AT 2PM
5. INJ. LASIX 40MG IV /BD ( IF SBP> 110MG)
6. INJ. HAI SC/ TID PREMEAL
7. TAB. BACLOFEN - XL 20MG
8. TAB. SPIRONOLACTONE 25MG PO/BD
9. TAB. UDILIV 300MG PO BD
10. TAB. RIFAGUT 55OMG PO/BD
11.SYP. LACTULOSE 100ML PO/BD
12. SYP. HEPAMERZ 10ML PO/BD
13.PROTEIN POWDER 2 TBSP IN 1 GLASS OF WATER PO TID
14. 2 EGG WHITES / DAY
15. GRBS 7 PROFILE MONITORING
16. STRICT I/O CHARTING
17. MONITOR VITALS BP/PR/RR/TEMPERATURE HOURLY
18.ABDOMINAL GIRTH AND WEIGHT MEASUREMENT

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