A 72 year old man with Ascites secondary to decompensated liver disease
1801006165 SHORT CASE
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A 72 year old man farmer by occupation came with the
CHIEF COMPLAINTS :
C/O abdominal distension since 1 month
C/O decrease appetite since 1 week
C/O decreased urine output since 1 week
Swelling of right lower limb since 2 days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 2 months ago then he developed pain in the abdomen which was insidious in onset, diffuse , intermittent non radiating.
He then noticed abdominal distension since 1 week which was gradually progressive increasing after food intake and no relieving factors
C/o decreased urination frequency i.e, 2-3 times a day
An ascitic fluid tap was done at KIMS which revealed high saag high protein with decreased sr. Amylase.He was diagnosed with ascites secondary to decompensated liver disease, spontaneous bacterial peritonitis with Heart failure with preserved ejection fraction and acute kidney injury.Patient got treated and CT abdomen findings were suggestive of Hepatocellular carcinoma He was then referred to MNJ cancer hospital where liver biopsy was done which showed no malignancy & was asked for repeat biopsy .Patient now again, presented with Abdominal distension which was progressive associated with shortness of breath since yesterday which aggravated on lying down relieved on sitting .Decreased urine output 1-2 times a day, dark yellow in colour not associated with burning micturition, urgency, frequency, dribbling, strangury
H/o episode of vomiting, 2 days ago 1 episode, ,non projectile, non bilious , foul smelling , non blood stained, containing food particles
H/o pedal edema in right leg followed by left leg progressive and pitting type
H/o constipation since 1 month
H/o reduced appetite since one week
H/O weight loss present (5-6 kgs in past 2 months)
No H/O fever, nausea, vomitings, loss of consciousness, pruritis
PAST HISTORY:
H/o similar complaints 1 month ago
Not a known case of DM, HTN, CAD, Asthma, Tuberculosis, Epilepsy.
No h/o previous blood transfusions
No h/o previous abdominal surgeries
FAMILY HISTORY:
Not significant
PERSONAL HISTORY :
Diet : mixed
Appetite: decreased
Sleep : disturbed
Bowel and bladder: deceased
Addictions alcohoic - occasionally
Non smoker
DRUG HISTORY -
Analgesic tablets and injections for pain in lower limbs since one year
ALLERGY HISTORY : no known allergies
GENERAL PHYSICAL EXAMINATION:
The patient is conscious, coherent, cooperative, well oriented to time, place and person.
PR - 102bpm
BP - 130/80 mmhg
RR - 20 cpm
SpO2 - 98% on RA
GRBS - 106mg/dl
Pallor+
Icterus present
B/l Pedal edema present
Tongue appears beefy and atrophic
No cyanosis, clubbing, koilonychia, lymphadenopathy
SYSTEMIC EXAMINATION
PER ABDOMEN:
INSPECTION:
Abdomen is uniformly distended
Umbilicus central and not everted
Flanks appear full
No scars , sinuses, dilated veins, visible pulsations
Hernial orifices are normal
Palpation
No local raise of temperature
No tenderness
Liver and spleen couldnot be palpable due to distention
Percussion
Shifting dullness present
Fluid thrill absent
Percussion
Liver borders
Upper border - 5th intercostal space
In midclavicular space
Lower border not elicited
Ascultation
Bowel sounds heard
RESPIRATORY SYSTEM
Inspection:
Shape of the chest elliptical
Equal chest movements
Trachea appears to be central
Palpation
Inspectory findings confirmed
Bilateral equal chest expansion
Trachea centre
Percussion
Resonant in all areas
Ascultation:
Bilateral air entry present
Normal vesicular breath sounds
CENTRAL NERVOUS SYSTEM
Higher mental functions - normal
Cranial nerves intact
Sensory system - pain , temperature, pressure , vibration intact
Motor system :
Tone - normal in upper and lower limb
Power Right left
Upper limb. 5/5 5/5
Lower limb 5/5 5/5
Reflexes Right. Left
Biceps ++ ++
Triceps ++. ++
Supinator ++. ++
Knee ++. ++
Ankle ++ ++
Plantar ++. ++
Cerebellum intact
No meningeal irritation
Liver function tests
SGPT - 117IU/L
ALP - 628IU/L
Total protein - 5.6gm/dl
Albumin - 2.23g/dl
A/G ratio 0.66
Serology-
HbsAg negative
Ultrasound-
Irregular and nodular border of the liver with altered echotexture
Hepatomegaly
Gross ascites Chest X ray
Ascitic fluid analysis-
Ascitic fluid tap was done yesterday night with due consent of the patient
Results-
LDH - 153 IU/L - decreased
Protein - 1.4 g/dl
Sugar- 73 mg/dl
Protein sugar within normal limits
Ascitic albumin - 0.67 g/dl
SAAG - high
Ascitic fluid Amylase- 31.7IU/L
Total count - 550 cells
Differential count
Neutrophils- 98%
Lymphocytes- 2%
PROVISIONAL DIAGNOSIS-
ASCITES SECONDARY TO DECOMPENSATED LIVER DISEASE
HEART FAILURE WITH PRESERVED EJECTION FRACTION (EF - 58%)
TREATMENT :
1. IV fluids NS at 30 ml/hr
2. Inj. Lasix 40mg iv/bd
3. Fluid restriction <2L/day
4. Salt restriction <1.2g/ day
5. Syrup lactulose 30ml PO/BD
7. Inj. Cefotaxime 2gm Iv/tid
8. BP ,PR monitoring every 4 th hourly
9. Abdominal girth and weight monitoring.
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