45 YR old male with abdominal distension

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I have been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan

D.Tejasri

Roll no -20

Case history-

A 45 years old male came with 

-c/o Abdominal distension since 4months

- SOB On  and off  since 4 months

 History of presenting illness-

Patient was apparently asymptomatic 4 months back then he developed abdominal distension which was ,Insidious in onset, gradually progressive in nature .

Since 1 month abdominal distension is progressive in nature for which he visited government hospital was diagnosed as ALD with portal Hypertension with Decompensated liver disease with Hepatic encephalopathy Grade 1 with Right pleural effusion mild. 

Pedal edema since 4 months insidious in onset gradually progressive ,relieved at night and aggrevated in morning (pitting type).

Sob present even at rest,orthopnea,PND present. 

No chest pain , palpitations.

C/o decreased urine output since 1 month since then patient is on Foleys catheter and 2 lit ascitic tap was done

PAST HISTORY

K/c/o Type 2 DM since 15 years and on medications 

    •INJ MIXTARD 5U BD since 3 years

Operated for iliospoas Abscess 10 months ago 

Not a  K/C/0 HTN,CAD, EPILEPSY, ASTHMA, TB , CVA ,THYROID DISORDERS 

PERSONAL HISTORY -

Appetite: Normal 

Diet-mixed

Bowel-Regular

Bladder- Decreased urine output since 1 month

Addictions:

Regular alcoholic since 15yrs

Occassional alcoholic since 4yrs (1- 2 times/ month)

2months ago patient consumed alcohol for 10days continuously 

General examination-

No pallor ,icterus, cyanosis, clubbing , lymphadenopathy 

Vitals-

Bp -110/70 mm hg

PR-96bpm

Temp-96.4 f

RR- 18cpm

SPO2- 98%on RA

Grbs - 125mg/dl

Systemic examination-

CVS-s1, s2 heard , no murmurs

RS-BAE present 

CNS- No focal neurological deficit 

 P/A- Distended and Fluid thrill present

Diagnosis:

Chronic Decompensated liver disease with k/c/o Dm ll since 15yrs.

Investigations:

Updated fever chart and investigations-

Treatment:

1.INJ Optineuron 1amp+100ml Ns /iv/OD

2.Tab lasilactone 20/50mg po BD 8am --- 4pm

3.syp.lactulose 15ml po BD 

4.syp Hepamerz 10ml po BD

5.High protein diet 2 egg whites/ day

6.protein powder 2tsps in 1 glass of water TID

7.Fluid restriction <2lit /day

8.salt restriction <2g /day

Follow up:

On 30/04/23

Vitals : 

BP- 110/70mmhg

PR -90bpm

RR-18cpm

Spo2 99% at room air 

GRBS - 91mg/dl

Temperature -98.6F

I/O :- 2950ml/1650 ml

Diagnosis-

Acute interstitial pancreatitis with acute kidney injury?prerenal  

-Pain abdomen relived 

-stool not passed

Treatment -

1.liquid diet and oral fluids.

2.INJ.pan 40mg/iv/od at 7am 

3.Inj zofer 4 mg/ iv /bd 

4.Inj thiamine 200 mg/iv/bd

5.inj Tramadol 100mg in 100 ml NS/iv/sos

6.strict I/O charting

7.IVF-20NS

On 01/05/24

-No fever spikes

Diagnosis:

Acute on Chronic decompensated liver disease 

Normocytic Normochrimic Anaemia (Hypoproliferative)

?Anemia of chronic disease

HRS-Chronic kidney disease ? Diabetic Nephropathy  with ? Porto pulmonary HTN

 Treatment-

1.fluid restriction < 2L/day

2.salt restriction < 2g/day 

3.INJ. optineuron 1amp +100 ml NS/IV/OD

4.Tab spiranolactone 2t5mg/po/bd 

5.Tab udiliv 300mg/PO/BD

6.T.Rifagut 550mg/PO/BD

7.syp lactulose 10ml/po/tid

8. Syp.Hepamerz 10ml/PO/BD

8.high protein diet 2egg whites/day 

9.protein powder 2tsps in 1 glass of water /po/tid 

10.Inj.vit k 1amp +100ml IV/OD

11.strict I/O charting

12.vitals monitoring 4th hourly

13.GRBS monitoring 6th hourly