75M DCLD ; HFpEF ; HCC ; DM

 C/O ABDOMINAL DISTENSION SINCE 1WEEK

 C/O DECREASED APETTITE SINCE 1 WEEK 

C/O DECREASED URINE OUTPUT SINCE AFTERNOON

 PT WAS APPARENTLY ALRIGHT 1MONTH BACK THEN HE DEVELOPED PAIN ABDOMEN ON AND OFF , THEN HE DEVELOPED ABDOMINAL DISTENSION , WHICH WAS INSIDIOUS IN ONSET , GRADUALLY PROGRESSIVE IN NATURE .


NO H/O FEVER , NAUSEA , VOMITING ,LOOSE STOOLOS , CONSTIPATION HE HAD LOSS OF APPETITE SINCE 1 WEEK AND DECREASE IN URINE OUTPUT SINCE AFTERNOON. NOT A K/C/O DM ,HTN , ASTHMA , TB , CAD , CVA , EPILEPSY OCCASIONAL ALCOHOL INTAKE , NO H/O SMOKING . 

GENERAL EXAMINATION : PT IS C/C/C, MODERATELY BUILT AND NOURISHED

 NO SIGNS OF PALLOR , ICTERUS , CYANOSIS , CLUBBING , LYMHADENOPATHY , EDEMA AFEBRILE 

PR -120BPM 

BP - 130/80 MMHG 

RR - 20CPM 

SPO2 - 98% AT ROOM AIR

 GRBS - 108MG% 

CVS - S1S2 HEARD , NO MURMURS

 CNS-HMF INTACT . NFND 

RS -BAE PRESENT , NO ADDED SOUNDS 

P/A - ABDOMEN DISTENDED , UMBILICUS CENTRAL , FLANKS FULL , NO ORGANOMEGALY , SHIFTING DULLNESS PRESENT , FLUID THRILL ABSENT, BOWEL SOUNDS HEARD


PROVISIONAL Diagnosis :-

ASCITIS SECONDARY TO DECOMPENSATED LIVER DISEASE[ HIGH SAAG HIGH PROTEIN ]

 SPONTANEOUS BACTERIAL PERITONITIS [ TC-1900]

 HEART FAILURE WITH PRESERVED EJECTION FRACTION [58]

 MULTICENTRIC HEPATOCELLULAR CARCINOMA ATYPICAL COMPLICATED HEMANGIOMA DENOVO DIABETES MELLITUS TYPE 2


Investigation

 USG ABDOMEN AND PELVIS - E/O LIVER IRREGULAR , NODULAR BORDER OF LIVER WITH ALTERED ECHOTEXTURE MILD HEPATOMEGALY GROSS ASCITIS 

2DECHO :

TRIVIAL TR /AR , NO MR NO RWMA , NO AS/MS , SCLEROTIC AV GOOD LV SYSTOLIC FUNVCTION

 CECT ABDOMEN; IMPRESSION; 

P/O 

1. ATYPICAL COMPLICATED HAEMANGIOMA

 2.MULTICENTRIC HEPATOCELLULAR CARCINOMA SUGGESTED FURTHER EVALUATION AND USG CORRELATION 

GROSS ASCITES LEFT PLEURAL EFFUSION

DIASTOLIC DYSFUNCTION , NO PAH /PE CULTURE AND SENSITIVITY OF ASCITIC FLUID - NO GROWTH ASCITIC FLUID CYTOLOGY - NEGATIVE FOR MALIGNANCY CELL COUNT OF ASCITIC FLUID - 1950 CELLS WITH 98% NEUTROPHILS , 2% LYMPHOCYTES ASCITIC FLUID SAAG- 1.24 , PROTEINS - 2.9 , LDH - 317 , AMYLASE - 20 , ALBUMIN -1.4


Treatment Given:-

 FLUID RESTRICTION LESS THAN 2LITRES PER DAY 

SALT RESTRICTION LESS THAN 1.2G PERDAY 

NEBULIZATION WITH IPRAVENT 6TH HRLY , 

BUDECORT 12TH HOURLY 

INJ CEFOTAXIM 2GM IV/TID

 INJ LASIX 40MG IV/BD

 TAB ALDACTONE 50MG PO/OD

 SYP LACTULOSE 30ML PO/BD 

SYP ASCORYL P 15ML PO/TID 

PROTEIN POWDER 2TABLESPOON IN 100ML MILK 

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