39YEAR OLD MALE WITH DISTENDED ABDOMEN


Case History and Clinical Findings
39YEAR OLD MALE CAB DRIVER BY OCCUPATION RESIDENT OF WEST BENGAL CAME TO
GM OPD WITH COMPLAINTS OF
ABDOMINAL DISTENSION SINCE 2 MONTHS
B/L PEDAL EDEMA SINCE 2 MONTHS
DECREASED APPETITE SINCE 2 MONTHS
DECREASED URINE OUTPUT SINCE 1 MONTH
HOPI:PATIENT WAS APPARENTLY ASYMPTOMATIC 2 MONTHS BACK THEN HE DEVELOPED
ABDOMINAL DISTENSION INSIDIOUS IN ONSET,GRADUALLY PROGRESSIVE ASSOCIATED
WITH DECREASED APPETITE SINCE THEN B/L PEDAL EDEMA UPTO KNEE SINCE 2 MONTHS
PITTING TYPE INCREASED ON WALKING AND RELIEVED ON REST.DECREASED URINARY
OUTPUT SINCE 1 MONTH INSIDIOUS IN ONSET,GRADUALY PROGRESSIVE.
NO H/O FEVER,COUGH,BREATHLESSNESS
PAST HISTORY:
NOT A K/C/O DM,HTN,ASTHMA,TB,EPILEPSY
NO H/O CVA,CAD
PERSONAL HISTORY
MIXED DIET
APPETITE -NORMAL
BOWEL -REGULAR
MICTURITION -NORMAL
NO KNOWN ALLERGIES
OCCASIONALLY ALCOHOLIC 180ML WEEKLY ONCE AND STOPPED 1 YEAR BACK
SMOKER BD - 1 PACK/DAY AND STOPPED 3 MONTHS BACK
FAMILY HISTORY - NOT SIGNIFICANT
GENERAL EXAMINATION:
PT IS CONSCIOUS, COHERENT, COOPERATIVE WELL ORIENTD TO TIME, PLACE, PERSON
MODERATELY BUILT AND NOURISHED
VITALS
BP : 110/70MM HG
PR 84 BPM
SPO2 98 % AT RA
TEMP 98.3 F
NO PALLOR , ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA
SYSTEMIC EXAMINATION
CVS S1 AND S2 +
RS NVBS HEARD, BAE +
P/A - SOFT,NON TENDER
CNS EXAMINATION:NO FOCAL NEUROLOGICAL DEFICITS
COURSE IN THE HOSPITAL:39 YEAR OLD MALE CAR DRIVER BY OCCUPATION RESIDENT OF
WEST BENGAL PRESENTED TO GM OPD WITH ABDOMINAL DISTENTION AND B/L PEDAL
EDEMA SINCE 2 MONTHS.AFTER THOROUGH CLINICAL EVALUATION AND INVESTIGATIONS
DIAGNOSED AS CHRONIC LIVER DISEASE AND DIAGNOSTIC TAP SHOWED HIGH SAAG LOW
PROTEIN FOLLOWED BY THERAPEUTIC TAP AND PATIENT IMPROVED
SYMPTOMATICALLY.HE THEN DEVELOPED CLOUDY TURBID AND HIGH COLOURED URINE
FOR WHICH UROLOGY REFERAL WAS DONE ON 12/12/23 AND X-RAY KUB AND
UROFLOWMETRY WAS DONE WHICH WERE FOUND OUT TO BE NORMAL RULING OUT
BLADDER CALCULUS AND STRICTURE URETHRA.LATER 24HR URINARY PROTEIN VALUE
SHOWED 3,834 MG/DAY AND 24 HR URINARY CREATININE SHOWED A VALUE OF
2.6GM/DAY.PATIENT IS SUSPECTED TO HAVE NEPHROTIC SYNDROME,TO CONFIRM THE
DIAGNOSIS RENAL BIOPSY WAS DONE ON 22/12/23 AND PATIENT IS BEING DISCHARGED IN
HAEMODYNAMICALLY STABLE CONDITION AND REVIEW TO GENERAL MEDICINE OPD WITH
RENAL BIOPSY AFTER 10 DAYS.
Investigation
BLOOD UREA20 mg/dl
42-12 mg/dl
SERUM CREATININE0.8 mg/dl1.3-0.9 mg/dl
LIVER FUNCTION TEST (LFT)
Total Bilurubin0.69 mg/dl
1-0 mg/dl
Direct Bilurubin0.18 mg/dl
0.2-0.0 mg/dl
SGOT(AST)136 IU/L
35-0 IU/L
SGPT(ALT)87 IU/L
45-0 IU/L
ALKALINE PHOSPHATE616 IU/L
128-53 IU/L
TOTAL PROTEINS4.5 gm/dl
8.3-6.4 gm/dl
ALBUMIN2.0 gm/dl
5.2-3.5 gm/dl
A/G RATIO0.80
HBsAg-RAPIDNegative Anti HCV Antibodies - RAPIDNon Reactive
COMPLETE URINE EXAMINATION (CUE)
COLOURPale yellow
APPEARANCEClear
REACTIONAcidic
SP.GRAVITY1.010
ALBUMINtrace
SUGARNil
BILE SALTSNil
BILE PIGMENTSNil
PUS CELLS3-4
EPITHELIAL CELLS2-3
RED BLOOD CELLSNil
CRYSTALSNil
CASTSNil
AMORPHOUS DEPOSITSAbsent
OTHERSNil
SAAG:1.65
SERUM ALBUMIN- 2.0 GM/DL
ASCITIC ALBUMIN- 0.35 GM/DL
CELL COUNT OF ASCITIC FLUID:
CLEAR, YELLOW
TOTAL COUNT- 50 CELLS/CUMM
NEUTROPHILS- 100%
USG DONE ON 16/11/23
IMPRESSION- COARSE ECHOTEXTURE OF LIVER S/P- CHRONIC LIVER DISEASE
SEVERE ASCITES WITH THIN INTERNAL SEPTAE
NORMAL DIRECTION AND CALIBER OF PORTAL VEIN
DIFFUSE GB WALL EDEMA DUE TO ASCITES

Diagnosis
DECOMPENSATED LIVER DISEASE
ASCITIS WITH HIGH SAAG
CYSTITIS (RESOLVED)
NEPHROTIC SYNDROME
Treatment Given(Enter only Generic Name)
TAB.LASILACTONE 20/50 PO BD
TAB.LEVOFLOXACIN 750MG PO BD x 7 DAYS
TAB.NIFTY-SR PO OD
SYP. LACTULOSE 15ML PO TID
SYP.ALKASTONE B6 15ML IN 1 GLASS OF WATER PO BD
STRICT ALCOHOL ABSTINENCE
Advice at Discharge
TAB.LASIX 20MG PO BD x 7 DAYS
TAB.SPIRONOLACTONE 25MG PO OD x 7 DAYS
SYP. LACTULOSE 15ML PO TID x 7 DAYS
SYP.ALKASTONE B6 15ML IN 1 GLASS OF WATER PO BD x 7 DAYS
Follow Up
REVIEW TO GENERAL MEDICINE OPD WITH RENAL BIOPSY REPORT AFTER 10DAYS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.





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