A 42 YR old male with ABDOMINAL DISTENSION

Case History and Clinical Findings

C/O ABDOMINAL DISTENTION SINCE 1 MONTH

C/O PEDAL EDEMA SINCE 1 MONTH

PATIENT WAS APPARENTLY ASYMPTOMATIC 1 MONTH BACK THEN DEVELOPED FEVER

LOW GRADE , ON AND OFF NOT ASSOCIATED WITH CHILLS AND RIGORS RELIEVED WITH

MEDICATION , LASTED FOR 3 DAYS , THEN DEVELOPED ABDOMINAL DISTENSION ,

INSIDIOUS ONSET AND GRADUALLY PROGRESSED TO PRESENT SIZE

PATIENT ALSO COMPLAINS OF PEDAL EDEMA SINCE 1 MONTH IT WAS INSIDIOUS IN ONSET

AND EXTENDED TILL MID-THIGH PITTING TYPE

H/O SOB,DECREASED URINE OUTPUT

H/O COUGH SINCE 4 DAYS , PAIN ABDOMEN

H/O CONSTIPATION SINCE 4 DAYS

H/O YELLOWISH DISCOLORATION OF THE EYES SINCE ONE MONTH

N/H/O BURNING MICTURITION , VOMITING , LOOSE STOOLS

N/H/O HAIR LOSS, LOSS OF APPETITE , MELENA

PAST ILLNESS:

K/C/O ALCOHOLIC LIVER DISEASE

N/K/C/O HTN,DM2,EPILEPSY,CVA,CAD,THYROID DISORDERS , TB, ASTHMA

TREATMENT HISTORY

6 ROUNDS OF ASCITIC FLUID TAPPING

PERSONAL HISTORY

OCCUPATION : AUTO DRIVER

APPETITE : NORMAL

DIET : MIXED

BOWELS : CONSTIPATION SINCE

MICTURITION : DECREASED FREQUENCY

ADDICTIONS : ALCOHOL SINCE 9 YEARS DAILY 250ML , LAST BINGE 1 MONTH AGO

BETEL LEAF(PAAN) : SINCE

GENERAL EXAMINATION

VITALS

TEMPERATURE : 99.4F

PULSE RATE : 98 BPM

BP: 110/70 MM HG

SPO2: 98% AT ROOM AIR

CVS: S1 S2 HEARD

RS: POSITION OF TRACHEA: CENTRAL. BAE PRESENT

PA: SOFT, NON TENDER, DISTENDED

ABDOMINAL GIRTH-

INSPIRATION-101CM

EXPIRATION-99.5CM

WEIGHT-62.5KG

HAIR LOSS+

TEMPORAL WASTING+

ICTERUS+

SPIDER NAEVI+

ASCITES+

ABDOMINAL GIRTH-12/4/24

INSPIRATION-97CM

EXPIRATION-96.5CM

ABDOMINAL GIRTH-14/4/24-99CM

COURSE IN THE HOSPITAL:

A 42YR OLD MALE CAME WITH C/O ABDOMINAL DISTENSION SINCE 1 MONTH AND B/L

PEDAL EDEMA SINCE 1 MONTH .PT WAS EVALUATED ACCORDINGLY AND FOUND

DERANGED LFT USG WAS DONE IT SHOWED CHRONIC LIVER DISEASE.,PATIENT WAS

TREATED ACCORDINGLY AND ASCITIC TAP WAS DONE ON 11/4/24(DAY 1) I/V/O DIAGNOSTIC

AND THERAPEUTIC PURPOSE ABOUT 1.5 LITRE ASCITIC FLUID WAS COLLECTED . ASCITIC

FLUID ANALYSIS SHOWED STERILE FLUID WITH HIGH SAAG LOW PROTEIN (INDICATIVE OF

? CIRRHOSIS)GASTROENTEROLOGY OPINION WAS TAKEN ,UGIE WAS DONE .IT SHOWED

GRADE 2 ESOPHAGEAL VARICES .TAB CARDIVAS 3.125 MG WAS STARTED.HYPOKALAEMIA

WAS EVALUATED AND CORRECTED .

REGULAR ASCITIC TAPS WERE DONE ON 13/4/24 AND 15/4/24 AND 2 LITRES OF ASCITIC

FLUID WAS COLLECTED EACH TIME .TOTAL BILIRUBIN LEVELS WERE IN DECREASING

TRENDS . PATIENT CONDITION IMPROVED AND VITALS ARE STABLE AT THE TIME OF

DISCHARGE

CNS: NFND

LEVEL OF CONSCIOUSNESS - CONSCIOUS

REFLEXES: RIGHT LEFT

BICEPS: ++ ++

TRICEPS: ++ ++

SUPINATOR: + +

KNEE: ++ ++

ANKLE: + +

GAIT - NORMAL

PSYCHIATRY REFERRAL DONE I/V/O ALCOHOL DEPENDENCE ON 13/4/24

ADVISE:

PATIENT COUNSELLED ABOUT THE NEED FOR STRICT ABSTINENCE FROM ALCOHOL AND

TOBACCO

NICOTINE GUMS 2MG (1/2MORNING-1/2AFTERNOON)

INJ.LORAZEPAM 1/2AMP/IM/SOS

GASTROENTEROLOGY OPINION WAS TAKEN

UPPER GI ENDOSCOPY WAS DONE

FINDINGS

GRADE II OESOPHAGEAL VARICES -3 COLUMNS

MILD PORTAL HYPERTENSIVE GASTROPATHY

ADVISE:T.CARDIVAS 3.125MG PO/BD

Investigation

HEMOGRAM ON 11/4/24

HAEMOGLOBIN - 7.5 GM/DL

TOTAL COUNT - 9,500 CELLS/CUMM

PCV - 19.8 VOL

MCV - 75.4 FL

MCH - 33.2 PG

MCHC - 37.9 %

RDW-CV 20.5 %

PLATELET COUNT 2.31 LAKHS/CU.MM

RBC COUNT 2.26 MILLIONS/CU.MM

SMEAR

RBC - NORMOCYTIC NORMOCHROMIC

WBC - NORMAL

PLATELETS - ADEQUATE

IMPRESSION - NORMOCYTIC NORMOCHROMIC

HEMOGRAM ON 13/4/24

HAEMOGLOBIN - 8.3 GM/DL

TOTAL COUNT - 7,700 CELLS/CUMM

LYMPHOCYTES-16%

PCV - 19.8 VOL

MCV - 75.4 FL

MCH - 33.2 PG

MCHC - 37.9 %

RDW-CV 20.5 %

PLATELET COUNT 2.31 LAKHS/CU.MM

RBC COUNT 2.26 MILLIONS/CU.MM

SMEAR

RBC - NORMOCYTIC NORMOCHROMIC

WBC - NORMAL

PLATELETS - ADEQUATE

IMPRESSION - NORMOCYTIC NORMOCHROMIC

HEMOGRAM ON 14/4/24

HAEMOGLOBIN - 8.5GM/DL

TOTAL COUNT - 8,000 CELLS/CUMM

LYMPHOCYTES-15%

PCV - 19.8 VOL

MCV - 75.4 FL

MCH - 33.2 PG

MCHC - 37.9 %

RDW-CV 20.5 %

PLATELET COUNT 2.34 LAKHS/CU.MM

RBC COUNT 2.26 MILLIONS/CU.MM

SMEAR

RBC - NORMOCYTIC NORMOCHROMIC

WBC - NORMAL

PLATELETS - ADEQUATE

IMPRESSION - NORMOCYTIC NORMOCHROMIC

COMPLETE URINE EXAMINATION (CUE) 11-04-2024 05:10:PMNORMAL

RFT

UREA 22mg/dl 50-17 mg/dlCREATININE 0.6mg/dl 1.3-0.8 mg/dlCALCIUM 0.97mg/dl 10.2-8.6

mg/dlSODIUM 134mmol/L 145-136 mmol/LPOTASSIUM 2.9mmol/L. 5.1-3.5 mmol/L.CHLORIDE

97mmol/L 98-107 mmol/L

S.ELECTROLYTES ON 12/4/24

SODIUM 135mmol/L 145-136 mmol/LPOTASSIUM 2.9mmol/L. 5.1-3.5 mmol/L.CHLORIDE

100mmol/L 98-107 mmol/L

CALCIUM 1.14mg/dl 10.2-8.6 mg/dl

S.ELECTROLYTES ON 13/4/24

SODIUM 135mmol/L 145-136 mmol/LPOTASSIUM 3.5mmol/L. 5.1-3.5 mmol/L.CHLORIDE

102mmol/L 98-107 mmol/L

CALCIUM 1.04mg/dl 10.2-8.6 mg/dl

S.ELECTROLYTES ON 13/4/24

SODIUM 135mmol/L 145-136 mmol/LPOTASSIUM 3.5mmol/L. 5.1-3.5 mmol/L.CHLORIDE

102mmol/L 98-107 mmol/L

CALCIUM 1.04mg/dl 10.2-8.6 mg/dl

S.ELECTROLYTES ON 14/4/24

SODIUM 134mmol/L 145-136 mmol/LPOTASSIUM 3.2mmol/L. 5.1-3.5 mmol/L.CHLORIDE

104mmol/L 98-107 mmol/L

CALCIUM 1.06mg/dl 10.2-8.6 mg/dl

S.ELECTROLYTES ON 15/4/24

SODIUM 134mmol/L 145-136 mmol/LPOTASSIUM 3.4mmol/L. 5.1-3.5 mmol/L.CHLORIDE

102mmol/L 98-107 mmol/L

CALCIUM 1.08mg/dl 10.2-8.6 mg/dl

USG ABDOMEN

IMPRESSION:

CLD

SPLENOMEGALY

GROSS ASCITES WITH INTERNAL ECHOES

MESENTERIC AND PERIPORTAL COLLATERALS

GB SLUDGE WITH GB WALL EDEMA

B/L RAISED ECHOGENICITIES OF KIDNEYS

ASCITIC FLUID MICROSCOPIS EXAMINATION:

FEW SCATTERED LYMPHOCYTES IN AN INFLAMMATORY BACKGROUND

NO E/O ATYPICAL CELLS.

URINE FOR C/S:NO GROWTH

STOOL FOR OCCULT BLOOD-NEGATIVE

FBS ON 12/4/24-75MG/DL

HbA1C-6.0%

ON 11/4/24

LDH-288IU/L

PT-18SEC

INR-1.33

BT-2MIN 30SEC

CT-5MIN 00SEC

APTT-35SEC

15/4/24

PT-20SEC

INR-1.4

APTT-38SEC

LIVER FUNCTION TEST (LFT) 11-04-2024

Total Bilurubin 20.73mg/dl 1-0 mg/dlDirect Bilurubin 15.14 mg/dl 0.2-0.0 mg/dlSGOT(AST) 174 IU/L

35-0 IU/LSGPT(ALT) 71IU/L 45-0 IU/LALKALINE PHOSPHATASE 184 IU/L 119-56 IU/LTOTAL

PROTEINS 6.8 gm/dl 8.3-6.4 gm/dlALBUMIN 2.64 gm/dl 4.6-3.2 gm/dlA/G RATIO 0.63

LIVER FUNCTION TEST (LFT) 13-04-2024

Total Bilurubin 18.71 mg/dl 1-0 mg/dlDirect Bilurubin 12.68 mg/dl 0.2-0.0 mg/dlSGOT(AST) 167 IU/L

35-0 IU/LSGPT(ALT) 69IU/L 45-0 IU/LALKALINE PHOSPHATASE 187 IU/L 119-56 IU/LTOTAL

PROTEINS 6.4 gm/dl 8.3-6.4 gm/dlALBUMIN 2.42 gm/dl 4.6-3.2 gm/dlA/G RATIO 0.61

LIVER FUNCTION TEST (LFT) 14-04-2024

Total Bilurubin 17.78mg/dl 1-0 mg/dlDirect Bilurubin 13.70 mg/dl 0.2-0.0 mg/dlSGOT(AST) 163 IU/L

35-0 IU/LSGPT(ALT) 65IU/L 45-0 IU/LALKALINE PHOSPHATASE 187 IU/L 119-56 IU/LTOTAL

PROTEINS 6.2 gm/dl 8.3-6.4 gm/dlALBUMIN 2.37 gm/dl 4.6-3.2 gm/dlA/G RATIO 0.62

SEROLOGY-NEGATIVE

ASCITIC FLUID ANALYSIS:

SUGAR-126 mg/dl

PROTEIN-0.7

AMYLASE-11.9IU/L

LDH-146IU/L

SAAG-2.27(HIGH)

Diagnosis

DECOMPENSATED CHRONIC LIVER DISEASE SECONDARY TO ALCOHOL

GRADE 2 ESOPHAGEAL VARICES

PORTAL HYPERTENSIVE GASTROPATHY

ALCOHOL AND TOBACCO DEPENDENCE SYNDROME

Treatment Given(Enter only Generic Name)

RX

INJ. THIAMINE 250MG IN 100 ML NS IV/BD

INJ.VIT-K 1AMP IM/OD

TAB. RIFAGUT 550 MG PO/BD 1-0-1

TAB.UDILIV 300 MG PO/BD 1-0-1

TAB.CARDIVAS 3.125 MG PO/BD 1-0-1

TAB. LASILACTONE 20/50 MG PO/BD 1-0-1

TAB.BENFOMET PLUS PO/BD 1-0-1

SYP. HEPAMERZ 20ML PO/BD 1-0-1

SYP.LACTULOSE 20ML PO/BD 1-0-1

SYP. ASCORYL LS 10ML PO/BD 1-0-1

3-4 EGG WHITES PER DAY

SYP. POTCHLOR 10ML PO/TID

PROTEIN POWDER 2 SCOOPS IN 150ML MILK / WATER PO/BD

Advice at Discharge

TAB. RIFAGUT 550 MG PO/BD 1-0-1 X15DAYS

TAB.UDILIV 300 MG PO/BD 1-0-1 X15DAYS

TAB.CARDIVAS 3.125 MG PO/BD 1-0-1 X15DAYS

TAB. LASILACTONE 20/50 MG PO/BD 1-0-1 X15DAYS

TAB.BENFOMET PLUS PO/BD 1-0-1 X15DAYS

SYP. HEPAMERZ 20ML PO/BD 1-0-1 X15DAYS

SYP.LACTULOSE 20ML PO/BD 1-0-1 X15DAYS

SYP. POTCHLOR 10ML PO/TID X3DAYS

SYP. ASCORYL LS 10ML PO/SOS

NICOTINE GUMS 2MG 1/2-1/2 X 15DAYS

PROTEIN POWDER 2 SCOOPS IN 150ML MILK / WATER PO/BD

3-4 EGG WHITES PER DAY

Follow Up

REVIEW TO GM OPD AFTER 1WEEK

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.