A 45 YR OLD MALE WITH ANEMIA

Case History and Clinical Findings

C/O ABDOMINAL DISTENSION SINCE 4 MONTHS

ON AND OFF SHORTNESS OF BREATH SINCE 4MONTHS

HISTORY OF PRESENTING ILLNESS-

PATIENT WAS APPARENTLY ASYMOTOMATIC 4 MONTHS AGO THEN HE STARTED C/O

ABDOMINAL DISTENSION WHICH WAS DISTENSION WHICHWAS INSIDIOUS IN ONSET AND

GRADUALLY PROGRESSIVE

SINCE 1 MONTH ABDOMINAL DISTENSION IS PROGRESSIVE IN NATURE FOR WHICH HE

VISITED GANDHI HOSPITAL AND WAS DIAGNOSD AS ALD WITH PORTAL HTN WITH

DECOMPENSATED LIVER LIVER DISEASE WITH HEPATIC ENCEPHALOPATHY GRADE 1 WITH

RT PLEURAL EFFUSION -MILD.

PEDAL EDEMA SINCE 4 MONTHS INSIDIOUS IN ONSET GRADUALIIY PROGRESSIVE

,RELIEVED AT NIGHT ,AGGRAVATED IN THE MORNING [PITTING EDEMA] -SOB DUE TO

ABDOMINAL DISTENSON , PRESENT EVEN ON REST ORTHOPNEA AND PND PRESENT

NO CHEST PAIN,PALPITATION. C/O DECREASED URINE OUTPUT SINCE 1 MONTH PATIENT

IS ON FOLEYS CATHETER SINCE THEN

-K/C/O DM 2 SINCE 15 YEARS

-OPERATED FOR ILIOPSOAS ABSCESS [10MONTHS AGO]

TREATMENT HISTORY-

INJ.MIXTARDBD FOR DM2

SURGERY FOR ILIOPSOAS ABSCESS

PERSONAL HISTORY-

PERSONAL HISTORY:

DIET-MIXED

APPETITE -NORMAL

BOWEL AND BLADDER - REGULAR

SLEEP-ADEQUATE

ADDICTIONS- REGULAR INTAKE SINE 15 YEARS ,10 DATS AGO PATIENT CONSUMED

ALCHOL CONTINOUSLY

ALLERGIES- NONE

FAMILY HISTORY:

INSIGNIFICANT

GENERAL EXAMINATION:

PATIENT IS CONSIOUS ,COHERNT ,COPERATIVE

NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY

VITALS:

TEMP-AFEBRILE

BP- 110/70MMHG

RR-18CPM

GRBS-125 MG/DL

SPO2-99% AT ROOM AIR

SYSTEMIC EXAMINATION:

CVS-S1 S2 HEARD NO MURMURS

CNS-NAD

RS-BAE+ NVBS

P/A -DISTENDED,SOFT NON TENDER,NO GUARDING,NO RIGIDITY, HERNIAL ORIFICES

NORMAL.

COURSE IN THE HOSPITAL-

PATIENT IS A KNOWN CASE OF CHRONIC DECOMPENSATED LIVER DISEASE SINCE 4

MONTHS WITH ASCITES .HE IS ON REGULAR MEDICATION FOR SAME SINCE 4-5 DAYS THE

ASCITES HAS AGGRAVATED AND PATIENT CAME FOR FURTHER EVALUATION.USG

ABDOMEN REVEALED GROSS ASCITES AND CIRRHOSIS OF LIVER.ON THOROUGH

CLINICAL,LABORATORY AND RADIOLOGICAL INVESTIGATION PATIENT HAS GROSS

ASCITES OF 4-5 LITRES.

THE WEIGHT OF PATIENT WAS 69KGS AND ABDOMINAL GIRTH WAS 89 CMS.DIAGNOSTIC

ASCITIC TAP DONE.-SHOWED HIGH SAAG AND LOW PROTEIN.THERAPEUTIC TAP OF 700ML

DONE.INJ.ALBUMIN 20 PERCENT GIVEN OVER 1 HOURINITIALLY HAD LOW URINE OUTPUT

AFTER ADDING LOW DOSE SPIRONOLACTONE PATIENTS URINE OUTPUT IMPROVED.

NEPHROLOGY OPINION TAKEN AND DIAGNOSED AS CKD.ADVISED FOR CONSERVATIVE

MANAGEMENT .

TREATMENT:

FLUID RESTRICTION LESS THAN 2.5 LIT/DAY

TAB.NODOSIS 500MG PO BD

TAB.OROFER XT PO OD

TAB.SHELCAL 500MG PO OD

DERMATOLOGY OPINION TAKEN FOR DIFFUSE XEROSIS OVER BILATERAL

FOREARM.MULTILE HYPERPIGMENTENTED MACULES NOTED ON PALMS ALONG WITH

ITCHING WAS DIAGNOSED AS PRURITIS SECONDARY TO CHRONIC LIVER

DISEASE.ACQUIRED DICTHYOSIS.ADVICED LIQUID PARAFFIN BD FOR 2

WEEKS.OPHTHALMOLOGY OPINION TAKEN FOR DIABETIC RETINOPATHY CHANGES.

IMP:RIGHT EYE NPDR

LEFT EYE PDR NOTED

ADVICED FOR GLYCEMIC CONTROL AND REVIEW TO OPD ON THURSDAY FOR RETINA

SPECIALIS

ON 30/05/2023 WEIGHT:71 KG ABDOMINAL GIRTH:92 CM AFTER TAP ----. 89CM ,WT -----.68KG.

2.5 LIT ASCITIC TAP DONE AND INJ.ALBUMIN 20 PERCENT GIVEN OVER 1 HR AND

SYMPTOMS OF SOB AND ABDOMINAL DISCOMFORT REDUCED.PRBC TRANSFUSION DONE

I/V/O SEVERE ANEMIA HB:6GM/DL.AFTER TRANSFUSION HIS HB WAS 8.7GM/DL.

GASTROENTEROLOGY OPINION TAKEN.ADVICED LARGE VOLUME PARACENTESIS ALONG

WITH 2 ALBUMIN TRANSFUSION ON DAY OF PARACENTESIS

REFERRED TO HIGHER CENTER-

- PATIENT AND PATIENTR ATTENDERS HAVE BEEN EXPLAINED ABOUT THELARGE VOLUME

PARACENTESIS ALONG WITH 2 ALBUMIN TRANSFUSION ON DAY OF PARACENTES NEED

FOR LIVER TRANSPLANTATIO REFERRAL ,AS THE PATIENT IS AN IDEAL CANDIDATE FOR

LIVER TRANSPLANTATION AS ADVISED BY THE GASTROENTEROLOGIST AND THE SAME

HAS BEEN EXPLAINED TO THE PATIENT AND PATIENT ATTENDER .AND WAS ADVISED TO

MEET THE LIVER TRANSPLANTATION TEAM

Investigation

HAEMOGRAM 28/4/23, 29/4/23 30/4/23 01/5/23

HB:6.0 ,6.1, 5.9, 8.7,

TLC:4700, 4800, 4500, 6300

PLATELET 1.65L 1.51L 1.88L 2.94

PCV:18.7 18.2, 18.2 26.1

ASCITIC FLUID - SUGAR - 104

 PROTEIN - 1.2

 LDH - 140

 CELL COUNT - 50CELLS/CUMM , 100% LYMPHOCYTES AND CLEAR.

CYTOLOGY REPORT

SPECIMEN : ASICTIC FLUID CYTOLOGY

MICROSCPY: CYTOMEAR STUDIED SHOWS SCATTERED LYMPHOCYTES FEW MESOTHELIAL

CELLS AGAINST PROTEINACEUS BACKGROUND

IMPRESSION: NEGATIVE FOR MALIGNANCY

2D ECHO:

EF-60%

MILD TR ;TRIVIAL MR ;NO AR

NO RWDA ,NOAS/MS

GOOD LV SYSTOLIC FUNCTIUON

DIASTOLIC DYSFUNCTION ,NO PAH

Diagnosis

ACUTE ON CHRONIC DECOMPENSATED LIVER DISEASE,

NORMOCYTIC NORMOCHROMIC ANEMIA [HYPOPROLIFERATIVE]

WITH ANEMIA OF CHRONIC DISEASE

HRS-CHRONIC KIDNEY DISEASE? DIABETIC NEPHROPATHY WITH ?PORTO PULMONARY

HTN

Treatment Given(Enter only Generic Name)

TAB.SPROINOLACTONE 25MG/PO/OD

TAB.RIFAGUT 550MG PO/BD

TAB.UDILIV 300MG PO/BD

SYP.LACTULOSE 15ML PO TID

TAB.LASILACTONE 5/25 PO/OD

SYP. HEPAMERZ 15ML PO/BD

TAB PAN 40 MG PO/OD BBF

FLUID RESTRICTION (2L/D)

SALT RESTRICTION (2G/D)

IV FLUIDS NS @ OUTPUT +30 ML/HR

PROTEIN POWDER 2TBSPS IN 1 GLASS OF WATER /PO/TID

INJ.VIT K IM