48 yr male with ascites, pedal edema since 2 months

 

48 yr male with ascites, pedal edema since 2 months

NAME : G PRAVALLIKA

ROLL NO: 41

8TH SEMESTER 

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients' problems through a series of inputs from an available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence based input.

This E-blog also reflects my patient centered online learning portfolio and your valuable inputs in the comment section are welcome.

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

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

CHIEF COMPLAINTS

 A 48 year old male came with chief complaints of           

• Abdominal distention since 2 months

• Bilateral pedal edema since 2 months

• Decreased appetite since 2 months

• Decreased urine output since 1 month

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 2 months ago, then he developed abdominal distention which is insidious in onset, gradual in progression associated with decreased appetite since the symptoms began. Bilateral pedal edema(pitting type) extending up to the knees since 2 months , increased on walking and relieved with rest. Decreased urinary output since 1 month.

No H/O fever, cough, breathlessness

PAST HISTORY :

No H/O DM, HTN, TB, Asthma, Epilepsy, CVA, CAD.

PERSONAL HISTORY :

• Consumes 180ml  alcohol occasionally and stopped 1 year back.

• Smokes beedi 1 pack per day and stopped 3 months back

GENERAL PHYSICAL EXAMINATION:

Patient is conscious ,coherent and cooperative and well oriented to time, place and person.

Moderately built and nourished.

Pallor- absent

Icterus- absent

Cyanosis- absent

Clubbing- absent

Generalised Lymphadenopathy- absent

Edema-bilateral pedal edema present

VITALS:

Temperature - 98.2F

PR :- 95 bpm

RR : 22cpm

BP :- 110/70 mm Hg

SPO2 :- 98%@RA

GRBS :- 110 mg/dl.

SYSTEMIC EXAMINATION 

Per abdomen - 

Abdominal girth- 93-->91 cm

Inspection- 

Abdomen is distended , flanks are full, skin is stretched  , no visible peristalsis , equal symmetrical movements in all quadrants with respiration.

Palpation - 

No local rise of temperature,  no tenderness

All inspection findings are confirmed by palpation, no rebound tenderness, guarding and rigidity.

No tenderness , No organomegaly 

Fluid thrill present 

Percussion:

Shifting dullness present 

Auscultation:

Bowel sounds heard 

CVS : S1 and S2 heart sounds heard

CNS: NO focal neurological deficits 

RR: BAE Present, normal vesicular breath sounds heard, no adventitious sounds

Shape of the chest: normal

Trachea appears to be central

Ascitic fluid

Chest x-ray 

USG abdomen 

PHES test

Interpretation:

INVESTIGATIONS 

Ascitic tap - 

• Appearance - clear , yellow coloured 

• SAAG - 1.65 g/dl

• Serum albumin - 2.0 g/dl

• Ascitic albumin - 0.35 g/dl

• Ascitic fluid sugar - 104 mg/dl

• Ascitic fluid protein - 0.7 g/dl

• Ascitic fluid amylase - 17 IU /L

• LDH : 143 IU/L 

• Cell count- 50 cells 

• Lymphocytes nil

• Neutrophils 100%.

TREATMENT :

• Tab LASIX 40 mg PO BD

• Syp. Lactulose 10 ml  PO HS

• Strict Alcohol abstinence .