Ascites secondary to Chronic liver disease

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This is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss individual patients' problems through a series of inputs from an available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based input.

This E blog also reflects my patient-centered online learning portfolio and your valuable input in the comment box are 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, and investigations, and coming up with diagnosis and treatment plan

The patient/attender was informed of the purpose of the information being acquired. Informed consent was taken from the patient/attender and there is the omission of information that was requested to be omitted.


P Sri Sai Sanjana

2019

Roll No: 96


DEMOGRAPHICS:

Age: 39 yrs

Gender: Male

Occupation: Cab driver

Address: West Bengal


CHIEF COMPLAINTS:

 A 39-year-old male came with chief complaints of:           

  • Abdominal distention since 2 months
  • Bilateral pedal edema since 2 months
  • Decreased appetite since 2 months
  • Decreased urine output since 1 month

HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic 2 months back. Then he developed abdominal distention which was insidious in onset, gradually progressive, and associated with decreased appetite.

Bilateral pedal edema extending up to knee since 2 months, pitting type, increased on walking and relieved with rest.

Decreased urinary output since 1 month 

No h/o fever, cough, breathlessness

No h/o pruritus, blood in vomiting and stools 




29/11/23



1/12/23





PAST HISTORY:

No h/o DM, HTN, TB, asthma, epilepsy, CVA. CAD

PERSONAL HISTORY:

  • Diet - mixed
  • Appetite - decreased 
  • Sleep - adequate 
  • Bowel and bladder movements - regular 
  • Consumes alcohol -180ml
  • Stopped consumption of alcohol from the day of admission 
  • Smokes beedi 1 pack per day and stopped 3 months back

Daily routine:

Patient wakes up at around 5:00 am every day and freshens ups. Have a cup of tea then at around 9 am has his breakfast (rice and dal). He goes cycling to his workplace. Then he will have his lunch at 1:00 pm and then comes back home around 9:00 pm. He then has dinner, consumes alcohol and goes to bed at 10:00pm.

Alcohol consumption is usually on alternative days.


GENERAL PHYSICAL EXAMINATION:

The patient is conscious, coherent, cooperative, and well-oriented to time, place, and person.

Moderately built and nourished.

Pallor - absent

Icterus - absent

Cyanosis - absent

Clubbing - absent

Generalized Lymphadenopathy - absent

Edema - Bilateral pedal edema, pitting type 


VITALS:

Temperature - afebrile 

PR: 95bpm

RR: 22cpm

BP: 110/70mm Hg


SYSTEMIC EXAMINATION 

Per abdomen-

Inspection-

Abdomen is distended, flanks are full, skin is stretched, umbilicus is everted, no visible peristalsis, equal symmetrical movements in all quadrant’s with respiration, no dilated abdominal veins

Palpation- 

No local rise of temperature,  no tenderness

All inspectory findings are confirmed by palpation, no rebound tenderness, guarding and rigidity

No tenderness, No organomegaly 

Fluid thrill present 

Percussion-

Shifting dullness present — dull note is heard from the level of umbilicus 

Auscultation-

Bowel sounds heard



CVS: S1 and S2 heart sounds heard, no murmurs

CNS: No focal neurological deficits 

RR: BAE Present, normal vesicular breath sounds heard, no adventitious sounds, shape of the chest: normal, trachea appears to be central


 Ascitic fluid

Appearance - clear, yellow coloured 

SAAG - 1.65 g/dl

Serum albumin - 2.0 g/dl

Asctic albumin - 0.35 g/dl

Ascitic fluid sugar - 104mg/dl

Ascitic fluid protein - 0.7 g/dl

Ascitic fluid amylase - 17 IU /L

LDH : 143 IU/L 

Cell count- 50 cells 

Lymphocytes nil

Neutrophils 100%.

Chest x-ray 


Fever Chart

USG abdomen 


PHES test



Apraxia Charting

Interpretation



INVESTIGATIONS:









30/11/23

Ward-9

Admission date- 16-11-23

S - No fever spikes, Stools passed

O - Patient is conscious, coherent, cooperative

Vitals-

BP - 100/60mmhg

PR - 74bpm 

RR - 16cpm

SpO2 - 98%

Temperature - afebrile

CVS-S1 &S2 heard, no murmurs

RS - BAE+ ,NVBS

P/A - Soft, Distended, abdominal girth - 86cm; weight - 46kg

CNS - No focal neurological deficits 

A- Ascites secondary to chronic liver disease 

P- Tab Lasik 20mg 

     Syrup lactulose 15ml

     Zecof cough syrup 5ml TID

     Strict alcohol abstinence

     Monitor vitals & inform SOS


1/12/23

Ward-9

Admission date- 16-11-23

S - No fever spikes, Stools passed

O - Patient is conscious, coherent, cooperative

Vitals-

BP - 110/70mmhg

PR - 76bpm 

RR - 17cpm

SpO2 - 98%

Temperature - afebrile

CVS-S1 &S2 heard, no murmurs

RS - BAE+ ,NVBS

P/A - Soft, Distended, abdominal girth - 86cm; weight - 46kg

CNS - No focal neurological deficits 


A- Ascites secondary to chronic liver disease


P- Tab Lasik 20mg 


     Syrup lactulose 15ml


     Zecof cough syrup 5ml TID


     Strict alcohol abstinence


     Monitor vitals & inform SOS


TREATMENT:

Tab LASIX 20 mg PO OD

Syp. Lactulose 15 ml  PO TID

Zecof Cough Syrup 5 ml PO TID

Strict Alcohol abstinence



EDUCATIONAL POINTS:











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