45 /F with ascitis under evaluation.
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.
A 45 year old woman , agricultural labourer by occupation came to the opd with
CHIEF COMPLAINTS:
- Abdominal distension since 2 month
- Decreased appetite since 1 month
- Loss of weight since 2 month
- Bilateral pedal edema since 5 days
HISTORY OF PRESENT ILLNESS :
Patient was apparantly asymptomatic 2 month back then she developed abdominal distension , which is insidious in onset and gradual in progression .
Abdominal distension was associated with abdominal discomfort, loss of appetite and gradual weight loss up to 4_5 kgs ? since month
With this complaints,she went a near by hospital where USG abdomen was done.Usg revealed moderate amount of ascitis for which she was given conservative management which is unknown for 20 days.she also found to have low hb ,low serum k+ and low calcium levels and adviced to use iron sucrose tablets and vitamin D (tab shelcal PO/OD) for 20 days.
Even after taking theconservative abdominal distension has not subsided hence she once again went to hospital where a repeat USG was done revealing gross ascitis. Her Hb, serum potassium and vit d levels were still found to be low , for which she was reffered to o
She also complains of Bilateral pedal edema ,which is of pitting type and gradually progressive extending up to knee and subsiding after taking rest & aggravating on walking since 3 days
PAST HISTORY :
Not a known case DM, HTN, TB, CVA, EPILEPSY.
PERSONAL HISTORY :
Diet - Mixed
Sleep- adequate
Appetite -decreased
Bowel and bladder movements -regular
No addictions
FAMILY HISTORY :
Her father & mother were k/c/o TB , and both expired 10 years back
MENSTRUAL HISTORY :
Age at menarche - 13 years
LMP - 4 years back
Before 4 years
- Cycles were regular
- 28 days cycle/3-5 days of flow
- Uses 3 pads/day
- Not associated with clots.
GENERAL EXAMINATION :
Patient is conscious, coherent and cooperative and well oriented to time place and person .
Moderately built and moderately nourished
# PALLOR - PRESENT
# BILATERAL PEDAL EDEMA OF PITTING TYPE PRESENT
Icterus -absent
Clubbing- absent
Cyanosis - absent
Koilonychia-absent
Generalised lymphadenopathy -absent
VITALS :
Temp: Afebrile
PR: 80 bpm
BP: 140/100 mm hg
RR: 15 cpm
Spo2 - 95% at RA
GRBS - 124 mg/dl
SYSTEMIC EXAMINATION
CVS :
Inspection:
Chest wall is bilaterally symmetrical.
No precordial bulge
Palpation:
JVP - normal
Apex beat - felt in the left 5th intercostal space in the mid clavicular line.
Auscultation:
S1, S2 heard , No murmurs
RESPIRATORY SYSTEM:
Position of trachea: central
Bilateral air entry +
Decreased breath sounds on right side
No added sounds.
PER ABDOMEN :
Inspection:
Shape of abdomen - ovoid
Abdomen is distended , umbilicus inverted.
Fullness of flanks present
Abdominal striae present
No dilated veins,scars or sinuses
No visible pulsations
No hernial orifices
Palpation : no tenderness
Percussion:
DULL NOTE present in flanks
SHIFTING DULLNESS +
Fluid thrill absent
Auscultation:
Bowel sounds heard
INVESTIGATIONS :
Hemogram
Hb: 8.3 gm/dL
TLC: 2,800 cells/cu mm
Neutrophils: 60%
Lymphocytes: 28 %
PCV - 24.8 vol %
MCV - 76.5 fl
MCHC - 33.5%
MCH - 25.6 pg
RBC: 3.24 millions/cu mm
Platelets: 1 lakh cells/cu mm
Blood grouping & Rh typing - A +ve
ESR- 95mm /1st hr
RETICULOCYTE COUNT -0.6%
Corrected RC count- 0.3%
Complete urine examination
Albumin: trace
Sugars: nil
PC: 3-4
EC: 2-3
RBC: 4-5
RENAL FUNCTION TEST : 
Serum creatinine: 0.9 mg/dl
Urea - 24 mg/dl
Sodium - 133 meq/l
K+ - 3.0 meq/l
Cl- 92 meq/l
LIVER FUNCTION TEST :
Total bilirubin: 1.21 mg/dl
Direct bilirubin: 0.53 mg/dl
SGOT: 10 IU/l
SGPT: 10 IU/l
ALP: 207 IU/l
Total protein: 6.9 gm/dl
Albumin: 3.6 gm/dl
A/G: 1.08
ASCITIC FLUID ANALYSIS :Cell count and type
Volume - 2ml
Color - yellow
Appearance - clearr
TC - 55 cells
Lymphocytes - 70%
Neutrophils - 30%
RBC - present
Serum albumin - 3.6 gm/dl
Ascitic albumin - 2.7 gm/dl
SAAG - 0.9
Serum LDH - 151 IU/l
Ascitic fluid :
- LDH - 93 IU/l
- protein - 4.8 gm/dl
- Sugar - 154 mg/dl
Ascitic fluid ADA - 19 U/l
CHEST X RAY - PA view
ECG
USG Abdomen
Impression- gross ascitis
2D ECHO
30/8/21 HEMOGRAM
*COOMBS TEST
Direct coombs : positive (1+)
Indirect coombs:positive (2+)
*1/09/21
Hemogram
Hb: 9.7 gm/dL
TLC: 2,200 cells/cu mm
Neutrophils: 60%
Lymphocytes: 25 %
PCV - 29.8 vol %
MCV - 76.0 fl
MCHC - 33%
MCH - 25.1 pg
RBC: 3.87 millions/cu mm
Platelets: 1 lakh cells/cu mm
SERUM ELECTROLYTES
Na- 135 meq/l
K- 3.7 meq/l
Cl-92 meq/l
Peripheral smear
RBC - Normocytic normochromic
WBC - within normal limits
Platelets - Adequate
ASCITIC FLUID CULTURE AND SENSITIVITY REPORT
2/08/21
MOUNTOUX TEST - NEGATIVE after 72 hrs
CBNAAT- NEGATIVE for TB
ASCITIC FLUID ANALYSIS (REPEAT)
CYTOLOGY
PROVISIONAL DIAGNOSIS
? ASCITIS (EXUDATIVE TYPE ) UNDER EVALUATION
? TUBERCULAR ASCITIS
FEVER CHARTING
TREATMENT
TREATMENT
1. Fluid restriction <1 litre/day
2. Salt restriction <2gm /day
3. Tab LASIX 40 mg PO/BD
4. Tab ALDACTONE 25 mg PO/OD
5. Daily abdominal girth & weight monitoring
6. BP charting 6 hrly
Pedal edema decreased------》resolved by day 4 of the treatment
Appetite decreased --------》improved by day 3
1. Fluid restriction <1 lt/day
2. Salt restriction < 2g/day
3. Tab LASIX 40 mg /PO/BD
4.Tab ALDACTONE 25 mg/PO/OD
5. Daily AG and weight monitoring
6. Bp charting 6th hourly
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