47/M With CLD
Author : Dr Zain Alam, Dr Raveen
This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input. This E-blog also reflects my patient's centred online learning portfolio. 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 a diagnosis and treatment plan.
A 47 year male patient came with chief complaints of abdominal distension and swelling of bilateral lower limbs since 6 months which is gradually increasing since 10 days and and fever since 2 days.
History of present illness
Patient was apparently asymptomatic 18 months back then he noticed abdominal distension which is insidious in onset and gradually progressive in nature and subsequently noticed bilateral swelling of lower limbs , he was hospitalized for one week and took medication which increased his urine output and abdominal paracentesis was done and felt better ,, However he discontinued medicine 6 months back and presented with similar complaints where he was hospitalized and treated conservatively , he was hospitalized 3 months back again with similar complaints , again abdominal paracentesis of 1.5 to 2 lit was done. He is on medication , the past 10 days he noticed abdominal distension associated with swelling of bilateral lower limbs which started at ankle and progressed upto knee
H/0 of fever, low grade,intermittent in nature not associated with chills, since 2 days,
H/0 of anorexia, fatigue and generalized weakness since 3 months,,
H/0 of disturbed sleep since one month, where he complained of excessive day time sleepiness and night distured sleep,
H/0 of yellowish discoloration of eyes 3 months back now it subsided,
No h/0 of nausea and vomitings,
No h/0 of pain abdomen
No h/0 of decreased urine output
No h/0 of high coloured urine and clay coloured stools.
No history of shortness of breath
No history of blood transfusions
Past medical illness-
History of abdominal distension , swelling of bilateral pedal oedema, and hematemesis one episode 50 ml 18 months back ,where he admitted in an hospital for 10 days which relieved with diuretics , abdominal paracentesis and gastric oesophageal ligation was done.
Appendicectomy 25 years ago
No history of hypertension, diabetes, thyroid , epilepsy or seizure disorder.
Personal history-
Diet - mixed
Sleep - disturbed , excessive day time sleep , night time disturbed sleep since one month.
Appetite- decreased.
Bladder habits- regular and normal.
Habits- chronic consumption of alcohol since 20 years daily , country liquor of 500 ml nearly 110gm per day, and whisky of 150 ml per day nearly 50gm per day,
Last binge of alcohol - 3 days before admission he took 100gm.
Summary - Decompensated chronic liver disease secondary to ethanol consumption, with ascites, portal hypertension, hepatic encephalopathy stage 1 and spontaneous bacterial peritonitis.
General examination -
Moderately built and nourished.
Patient is oriented to time , place and person.
GCS - E4 V5 M6
VITALS -
Pulse - 82 beats per minute, regular normal volume ,and character, no radio radial or radio femoral delay.
Blood pressure - 100/70 mm Hg, right arm supine position.
Respiratory rate - 18 cpm, thoracoabdominal.
Spo2- 98 % on room air
Jvp - not elevated.
Physical examination-
pallor - present
Icterus - absent
No cyanosis
No clubbing
No generalized lymphadenopathy
Pedal edema +
Head to toe examination-
Axillary and public hair - sparse.
B/ l parotid enlargement - negative
No fetor hepaticus
No asterixis
No gynaecomastia
Spider nevi - absent
No planar erythema
No leuconchyia
Inspection -
Oral cavity - No dental caries and no Tobacco staining
Abdomen - flanks full, distension.
Appendicectomy scar present.
Distened veins present.
No visible peristalsis or no visible pulsations.
Palpation -
Done in supine position with Both Limbs flexed and hands by side of body.
No tenderness or local rise of temperature.
Abdomen - soft.
No gaurding and rigidity
Hepatomegaly present
Spleen not palpable
Kidneys bimanually palpable , ballotable.
Fluid thrill - present
Abdominal girth - 98 cms .
Xiphisternum to umbilicus - 16 cms
Public symphysis to umbilicus - 13cms
Percussion -
Liver span - 15.7 cm in mid-clavicular line
Auscultation :
Normal bowel sounds heard.
No hepatic bruit , venous hum or friction rub.
Examination of external genitilia - No testicular atrophy.
Examination of spine - Normal.
Provisional diagnosis -
Decompensated chronic liver disease
Etiology - chronic ethanol related.
Ascites , Hepatic encephalopathy grade 1
Esophageal gastric ligation bands were.
Child-Pugh SCORE - C
MELD SCORE - 9
Investigations-
CBP -
HB - 7.3
TLC - 9600
PLT - 1.97 LAKH
CUE -
Albumin- trace
Sugar- nil
Rbcs- nil
Pus cells - 2 to 3
RFT -
Blood urea - 12mg/ dl
Serum creatinine - 0.7mg/dl
Sodium - 139 meq/l
Potassium - 3.4meq/l
Chloride - 99 meq/l
Uric acid - 5.0
Calcium - 9.1
Phosphorus - 7.0
LFT -
Total bilirubin - 10.46 mg/ dl
Direct bilirubin - 8.84mg/dl
SGOT - 140IU/L
SGPT - 17 IU/L
ALP - 321 IU/L
Total protein - 6.9gm/dl
Albumin - 2.2 gm/ dl
RBS- 70mg/dl
Ascitic fluid analysis -
SAAG - 1.85. Serumalbumin - 2.2
Ascitic albumin - 0.35
Ascitic LDH - 38 IU/ L
Ascitic sugar - 126mg/ dl
Ascitic protein - 0.8 g/dl
Appearance - Clear
Total count: 50 cells
DLC:80% neutrophils
20% lymphocytes
RBCS - nil
Impression: Negative for malignancy
PT - 18 Sec.
APTT - 35sec.
INR - 1.33
BGT AB+
Hiv - negative.
Hbsag -negative.
Hcv - negative
CHEST X-RAY AP VIEW
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