47 years old male patient with abdominal distension





47 years old male patient, auto- rickshaw driver by occupation presented to casuality with complaints of abdominal distension since 10 days.

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:


ECG:




Ascitic tap was done on 12/12/21.

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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