56 yr female with abdominal distension since 20 days.

56yr female with abdominal distension since 20 days
July 07, 2023






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

Pt came with the complaints of 

Abdominal distension since 20 days
Pedal edema upto knees since five days

History of presenting illness

Pt was apparently asymptomatic 20 days ago then she developed abdominal distension, which was insidious in onset, gradually progressive in nature
Abdominal tightness present 
aggrevated after having food

Patient has pedal edema since five days- on and-off which is continuous,pitting type, upto knee level 
Patient complains of SOB when abdominal bloating is present
No c/o chestpain, palpitations ,orthopnea, PND
No fever, cough, cold, vomitings ,loosestool

PAST HISTORY:
She is a k/c/o chronic liver disease since 1 yr
Pt was admitted with similar complaints 11 months back and therapeutic ascitic tap was done

K/c/o HTN since 13 years on tab Telma 40 MG PO/OD
K/c/o Hypothyroidism since13 years on tab.thyronorm PO/OD
K/c/o DM type 2 since 4 yrs on metformin 500mg PO/OD

Not a k/c/o asthma,CVA,CAD,TB,epilepsy

PERSONAL HISTORY:

Diet-mixed

Appetite:normal 

Bladder movements -regular
Bowel-Has constipation 

Addictions-beetelnut(pan) since 30yrs

Sleep -adequate

GENERAL EXAMINATION:

Patient was consious, coherrent and co-operative. Well oriented to time place and person.moderately built and nourished 

icterus -present
B/L pedal edema-present (upto knee level-pitting)



No pallor 
No clubbing
No cynosis
No generalized lymphadenopathy 

Vitals: 
Temp: afebrile
Bp: 100/70 mmHg
PR: 72bpm
RR: 20 cpm
SpO2: 98% on RA

Systemic Examination -

ABDOMEN :

Abdomen - distended 

Normal hernial orifices 

Fluid thrill + 

Dilated veins absent

No tenderness 

No palpable mass 

No organomegaly 

No brui heard

CVS : 
S1 S2 + ,No murmurs

RESPIRATORY SYSTEM;
B/l symmetrical chest
Trachea - Central
B/l air entry present
NVBS heard

CNS:NFND

Investigations:
2D Echo
MRI abdomen and pelvis:
USG Abdomen and pelvis:
USG ( after ascitic tap)

Ascitic fluid sugar:187mg/dl
Ascitic fluid Protien:1.5gm/dl
Ascitic fluid for LDH:710 IU/L
Cell count of Ascitic fluid:
Total cells:100cwlls/cumm 
Neutrophils:nil
Lymphocytes:100%

LFT:
Total bilurubin:3.65mg/dl
Direct bilurubin: 1.51mg/dl
SGOT: 179IU/L
SGPT: 152IU/L
Alkaline phosphate:190 IU/L
Total proteins:5.2gm/dl
Albumin: 2.84g/dl

Fasting blood sugar: 112mg/dl

Hemogram:

Hb:15.2gm/dl
TLC:10200cells/cumm
Neutrophils 86%
Lymphocytes 8%
Eosinophils 2%
MCV-89.5fl
MCH-31.3pg
MCHC-34.9%
RBC count:4.87millions/cumm
Platelets:2.39lakh/cumm 

PROVISIONAL DIAGNOSIS:

Decompensated chronic liver disease ?with k/c/o HTN and hypothyroidism since 13yrs

K/c/o DM-II since 3 yrs

TREATMENT GIVEN:

1.Fluid restriction <1L per day

2.salt restriction <2g/day

3.tab.udiliv 300mg PO/BD 

4.tab.rifagut 550mg PO/BD

5.tab.lasilactone 20/5mg PO/OD 

6.Syp.lactulose 10ml PO/TID 

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