48 year old male with Ascites and pedal oedema since 2 months

This is an a 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 series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is 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 alright 2 months back then he developed abdominal distention which is insidious in onset gradually progressive associated with decreased appetite since then. 

Bilateral pedal edema extending upto knee since 2 months , pitting type 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 :- 95bpm

RR : 22cpm

BP :- 110/70mm Hg

SPO2 :- 98%@RA

GRBS :- 110mg/dl.

SYSTEMIC EXAMINATION 

Per abdomen - 

Abdominal girth- 93-->91cm

Inspection- 

Abdomen is distended , flanks are full, skin is stretched , no visible peristalsis , equal symmetrical movements in all quadrant’s with respiration 

Palpation - 

No local rise of temperature, no tenderness

All inspectory findings are confirmed by palpation, no rebound tenderness, gaurding 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

                            USG abdomen 

PHES test

Interpretation

INVESTIGATIONS 

Ascitic tap - 

Appearance - clear , yellow coloured 

SAAG - 1.65 g/dl

Serum albumin - 2.0 g/dl

Asctic albumin - 0.35 g/dl

Ascitic fluid sugar - 104mg/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 .