47 years old male patient with abdominal distension
History of present illness:
Patient was apparently asymptomatic 5 months ago. Then he developed abdominal distension. For which ascitic tap was done. Then he was on medication for 5 months. Gradually started tapering them from 1 month. 10 days ago he developed abdominal distension which was gradual in onset, painless, associated with b/l pitting Edema of lower limbs (above thighs i.e. grade 4).
5 days back he developed decreased urinary output which has been decreasing progressively since then.
C/o burning micturition.
No h/o hematuria.
No h/o Dyspnea, palpitations, chest pain.
No vomitings, no loose stools, no cough, no sore throat.
Past history: 6 months back, he was diagnosed with HBsAg positive status
Not a K/C/O DM, HTN, TB, Epilepsy, Asthma.
No H/O similar complaints in the past
Personal History:
Married
Occupation- Auto- rickshaw driver
Diet - mixed
Appetite - normal
Sleep - normal
Bowel habits - regular
Addictions- Stopped consuming alcohol 4 years ago.
No known allergies.
Family History - Not significant
GENERAL EXAMINATION:
Pallor- present
Icterus present
No cyanosis,clubbing,lymphadenopathy
Edema- B/L pitting Edema above thighs (Grade IV)
K/C/O Psoriasis and on medication since 10 years. Stopped using medication since 1 year. Has been using Ayurvedic medicine since last month (with gradual tapering of dose).
Vitals on Admission:
Temp. - 98.2 F
PR - 110 bpm
RR - 20 cpm
BP - 170/100 mmHg
SpO2 - 99% at RA
SYSTEMIC EXAMINATION:
CVS - S1, S2 heard , No murmurs
RESPIRATORY SYSTEM: B/L Air Entry +
P/A -
- Shape of abdomen- Obese
- All quadrants moving equally with respiartion.
- No scars and sinuses.
- No hepatomegaly.
- No splenomegaly.
- Hernial orifices free.
- Bowels sounds heard.
- Gross ascites+, Shifting dullness+
CNS - NAD
PROVISIONAL DIAGNOSIS: Decompensated liver disease secondary to chronic liver disease with HBsAg positive status with moderate ascites with alcoholic with psoriasis
INVESTIGATIONS:
12/12/21
Serology- HBsAg positive
CBP:
Hb- 12 gm/dl
TLC- 9300
Plt- 1.54 lakhs/cu. mm
LFT:
TB- 2.94
DB- 1.66
AST- 37
ALT- 24
ALP- 259
TP- 6.5
ALBUMIN- 2.4
A/G RATIO- 0.59
RFT:
UREA- 42 mg/dl
CREATININE- 1.8 mg/dl
SODIUM- 144 mEq/L
POTASSIUM- 4.2 mEq/L
CHLORIDE- 104 mEq/L
CUE:
Colour- cloudy
Appearance- reddish
Reaction- acidic
Specific gravity-
Albumin- trace
Sugar- nil
Bile salts-
Bile pigments-
Pus cells- 5-6
Epithelial cells- 3-4
RBCs- plenty
Crystals-
Casts-
PT- 17 seconds
APTT- 33 sec
INR- 1.2
RBS- 99 mg/dl
CXR- PA VIEW:
Ascitic fluid:
Sugar- 151 mg/dl
Proteins- 6.7
SAAG- 2.0
Since the SAAG ratio is high (>1.1) ascites could be because of portal hypertension.
Ascitic fluid cell count
Serum albumin: 2.2 gm/dl
USG Abdomen:
Dermatology referral taken in view of Psoriasis.
Treatment given:
1. Inj. LASIX 40 mg I.V. BD
2. Tab. ALDACTONE 50 mg PO OD
3. Syp. LACTULOSE 10 ml PO BD
4. Fluid restriction <1 Litre/day
Salt restriction <2 gm/day
5. GRBS 12th hourly
SOAP NOTES-
13/12/21
S-
No fresh complaints
O-
Pt isC/C/C
Afebrile
BP- 120/80 mmHg
PR- 75bpm
Wt- 83 kg
AG- 111 cm
CVS- S1S2 +
RS- BAE+
P/A- subcutaneous edema+, shifting dullness+
CNS- NAD
A-
DECOMPENSATED LIVER DISEASE 2° to CHRONIC LIVER DISEASE
HBsAg +
Moderate ascites+ (high SAAG), alcoholic+
Psoriasis+
P-
Inj.LASIX 40mg IV BD if SBP>100 mmhg
Tab.ALDACTONE 50mg PO OD
Tab.RIFAGUT 750mg PO BD
Syp.HEPAMERZ 10ml PO BD
Syp.LACTULOSE 10ml PO BD (to pass stools 2-3 times/day)
Grbs 12th hrly
Fluid restriction < 1lit/day
Salt restriction <2g/day
14/12/21
S-
No fresh complaints
O-
Pt is conscious, coherent, cooperative
Temp - Afebrile
BP- 130/80 mmHg
PR- 78 bpm
Wt- 82 kg
AG- 106.68 cm
CVS- S1S2 +
RS- BAE +
P/A - subcutaneous edema+, shifting dullness+
CNS- NAD
A-
DECOMPENSATED LIVER DISEASE 2° to CHRONIC LIVER DISEASE
HBsAg +
Moderate ascites+ (high SAAG), alcoholic+
Psoriasis+
P-
Inj.LASIX 40mg IV BD if SBP>100 mmhg
Tab.ALDACTONE 50mg PO OD
Syp.LACTULOSE 10ml PO BD (to pass stools 2-3 times/day)
Grbs 12th hrly
Fluid restriction < 1lit/day
Salt restriction <2g/day
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