Hello everyone ! Iam an intern in the medicine department.one of the important terms of getting the internship completion is to complete my log book with my daily log with what i learn during the course of my duties
ascitic tap was done on day 1 and day 2. Approximately500 ml of ascitic fluid was taken ou t on day 1 and day 2
Case presentation:
72 yrs old male patient from suryapet came with the complaints of increased abdominal distension since 15 days
Pedal edema since 10 days with B/ L pitting type up to knee joint
HOPI: patient had yellowish discolouration of eyes 6months back and high coloured urine patient had abdominal distension and pedal edema bilateral pitting type since 6 months patient was on alcohol abstinence since 6months .These complaints again aggrevated after he started drinking 15 days back for 5 days .
Abdominal distension since 15 days and Pedal edemal was B/L pitting type,painless,up to knee joints since 10 days patient passed stools twice today.
No facial puffiness,pain abdomen,fever,SOB, orthopnea,PND,nausea,vomitings,chest pain,loose stools, palpitations
Bowel and bladder movements : regular
PAST HISTORY:
Patient had yellowish discolouration of eyes 6 months back with high coloured urine followed by abdominal distension .He went to hospital afterwards.
He used
TAB Lasilactone 20/50 for 6 months
PAST SURGERY:
Bowel gangrene 50 yrs back
Post GJ status ( documents not available)
Personal history:Diet : mixed
Appetite: normal
Sleep: adequate
Bowel and bladder movements: regular
Addictions: Taking 180 ml whiskey / day since 40 yrs
Stopped drinking 6 months back.
Then he drank continuously for 5 days 15 days back after which he developed the symptoms.
Smoking since 40 years
Smokes 25 bidis per day
Stopped before 2 years
General examination: pt is conscious, coherent,cooperative
malnourished ( cachexia)
BP: 110 /80 mm Hg
PR : 82 bpm
RR : 16 cpm
Temperature: afebrile
pallor,icterus, pedal edema present
No cyanosis,clubbing
Head and neck examination:
pallor,icterus,alopecia: present
parotid enlargement,fetur hepaticus,bleeding gums,sub conjuctival hemorrhages,xanthelsema, bitots spots,KF rings,medial supraciliary
TRUNK:
Loss of axillary and pectoral hair present
Testicular atrophy ,abdominal distension,wasting- present
spider nevi,gynecomastia, breast atrophy ,caput medusae,pupura,strech marks absent
U/ L: Duyptrens contracture present
clubbing,flapping tremors,pruritic marks,palmar erythema absent
L/L : B/ L Pitting type of pedal edema present.
SYSTEMIC EXAMINATION:
ORAL EXAMINATION:
oral thrush,tonsillitis,pharyngeal deposits,post nasal drip,dental caries,gum hypertrophy
absent
ABDOMINAL EXAMINATION:
INSPECTION:Shape : distended
flanks: full
umbilicus: everted
skin : streched , shiny ( scar is present over
No sinuses,strikes,nodules,scratch marks,puncture marks,dilated veins,visible gastric pulastions
PALPATION: Superficial palpation: warmth
Deep : liver and spleen : not palpable
abdominal girth:90 cm
PERCUSSION: shifting dullness present suggesting of fluid about 1000 ml
AUSCULTATION:Bowel sound heard
RESPIRATORY SYSTEM:
Bilateral air entry present
Normal vesicular breath sounds heard
CVS EXAMINATION:
S1 ,S2 heard
No murmurs
CNS EXAMINATION:
Higher mental function : Intact
Patient is conscious
Speech: normal
No signs of meningeal irritation
Cranial nerves: intact
Motor system : Tone:normal in all the limbs
Power: 5 / 5 in all the limbs
Biceps. Triceps. Supinator. Knee. Ankle
RIGHT. +2. +2. +2. +2. +2
LEFT. +2. +2. +2. +2. +2
GAIT: normal
GCS : 15 /15
INVESTIGATION:
Investigation
usg abdomen:
gross ascitis
bilateral grade 1 rpd
coarse ecotexture of liver with irregular surface chronic liver disease
HEAMOGRAM
HB 7.1
TC 5800
MCV 83.4
RBC 2.43MILLION
PLATELET COUNT 95000
CUE:
colour: pale yellow
color pale yellow appearence clear reaction acidic pus cells :2to4 epithelial cells: 2to 4
RFT
urea 22
08-07-2020 creatinine 1.5
10-07-2020 CREATININE 1.3
LFT
TOTAL BILIRUBIN 1.84
DIRECT BILIRUBIN 0.70
SGOT 40
SGPT 26
ALP 225
TOTAL PROTIENS 5.8
ALBUMN 2.7
A/G RATIO 0.89
PT 18 ,APTT 35,INR 1.3
STOOL FOR OCCULT BLOOD :NEGATIVE
ENDOSCOPY :
oesophagus :oesophageal varices grade 1 column and grade 2 column stomach post GJ status duodenum :deformed cap D2 not entered
impression :low grade portal hypertension ,post GJ status ,no active bleed
2D ECHO
EF 64%
RA RV DILATED LA DILATED WITH NO RWM
ASCITIC FLUID ANALYSIS:
ascitic fluid sugar 116
ascitic fluid protein 1.0
SAAG [HIGH SAAG LOW PROTIEN )
serum albumin 2.7
ascitic albumin 0.6
saag 2.1
ASCITIC FLUID AMYLASE 20
ASCITIC FLUID LDH 78
Child pugh score:Class B
MELD Score: 15 points
DF : 11 points
DIAGNOSIS:
Chronic decompensated liver disease
Cirrhosis with portal hypertension with oesophageal varices Grade 2 post GJ status
TREATMENT Given
- salt restriction less than 2 gm per day and fluid restriction
-TAB Lasilactone 40 / 100/ BD
- Syrup zincovit 5 ml / TID
- protein powder 2 tbsp in half glass of milk/ TID
- Two egg whites per day
- Tab Atenolol 50 mg / OD
- I/O Charting
-Monitor BP,PR,RR
- Daily abdominal girth and wt measurement
- TAB Pan 40 mg OD
- Inj optineuron 1 amp in 100 ml NS IV/OD
- Inj Thiamine in 100 mg in 100 ml NS IV / BD
- Syp Lactulose 10 ml / HS
Abdominal girth : on day one: 97 cm
on day two: 92 cm
on day three : 90 cm
Body weight :
Day 1 : 56 kgs
Day 2 : 54 kgs
Day 3 : 53 kgs
ADVICE AT DISCHARGE:
TAB LASILACTONE 20/50/2TABS /BD
SALT RESTRICTION DIET <2GM/DAY AND FLUID
RESTRICTION
TAB THIAMINE 100MG/BD
TAB PAN 40MG /OD
SYR ZINCOVIT 5ML/TID
SYRLACTULOSE 10ML H/S
TAB PROPANOL 20MG /OD
PROTIEN EX POWDER 2 TBSP IN HALF
GLASS OF MILK /TID
TWO EGG WHITES/DAY
