CASE OF 45/F WITH ASCITIS UNDER EVALUATION
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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.
A 45 year old woman , agricultural labourer by occupation came to the opd with
CHIEF COMPLAINTS:
- Abdominal distension since 1 1/2 month
- Decreased appetite since 1 month
- Loss of weight since 1 month
- Bilateral pedal edema since 3 days
HISTORY OF PRESENT ILLNESS :
Patient was apparantly asymptomatic 1 1/2 month back then she developed abdominal distension , which is insidious in onset and gradually progressive.
Abdominal distension was associated with abdominal discomfort, loss of appetite and gradual weight loss (? up to 5 kgs) since 1 month
For the above mentioned complaints,she went a local hospital where USG abdomen was done.Usg revealed moderate amount of ascitis for which she was given conservative management (? Medication 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 though after taking the above medications her 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 kims .
She also complains of B/L 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 k/c/o DM, HTN, TB, CVA, CAD, Asthama ,thyroid and epilesy
She underwent tubectomy 23 yrs back
No h/o previous blood transfusions
PERSONAL HISTORY :
Mixed diet
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/pain
OBSTETRIC HISTORY:
Marrital status - 27 years back
Antenatal history is uneventful in all the 3 pregnancies
1st child : girl - FTNVD (26yrs) - 2.5kg
2nd child : boy - FTNVD (25yrs) -2.4 kg
3rd child : boy - FTNVF (24yrs) - 2.5 kg
GENERAL EXAMINATION :
Patient is conscious, coherent and cooperative
Moderately built and moderately nourished
PALLOR + , B/L PEDAL EDEMA PITTING TYPE +
No icterus,clubbing,cyanosis,koilonychia, and lymphadenopathy
VITALS :
Temp: Afebrile
PR: 84 bpm
BP: 150/100 mm hg
RR: 16 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 in the right IAA & IMA
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
CNS :
Patient is Conscious
Speech: normal
No signs of Meningeal irritation
Motor & sensory system: normal
Reflexes: present
Cranial nerves: intact
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 - 95 mm /1st hr
Reticulocyte count - 0.6 %
Corrected RC count - 0.3
Coagulation profile
PT - 16
INR - 1.11
APTT - 33
CUE
Albumin: trace
Sugars: nil
PC: 3-4
EC: 2-3
RBC: 4-5
RFT :
Serum creatinine: 0.9 mg/dl
Urea - 24 mg/dl
Sodium - 133 meq/l
K+ - 3.0 meq/l
Cl- 92 meq/l
LFT :
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
RBS - 159 mg/dl
Serology - negative
ASCITIC FLUID ANALYSIS :
Cell count and type
Volume - 2ml
Color - yellow
Appearance - clear
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
CXR - PA view
ECG
USG Abdomen
Impression - gross ascitis
2D Echo
30/08/21
Hemogram
COOMBS TEST
Direct coombs : positive (1+)
Indirect coombs : positive (2+)
31/08/21
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
Chloride - 92 meq/l
Peripheral smear
RBC - Normocytic normochromic
WBC - within normal limits
Platelets - Adequate
PROVISIONAL DIAGNOSIS
? ASCITIS (EXUDATIVE TYPE ) UNDER EVALUATION
? TUBERCULAR ASCITIS
FEVER CHARTING
TREATMENT
DAY 0
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 th hourly
DAY 1
SOAP NOTES :
SUBJECTIVE :
Pedal edema decreased
Appetite decreased
OBJECTIVE :
Temperature - afebrile
BP - 150/100 mm hg
PR - 86 bpm
RR - 16 cpm
SPO2 - 98 % at RA
GRBS - 126 mg /dl
29/08/21
Abdominal girth - 86 cm
Weight - 53 kgs
30/08/21
Abdominal girth - 82 cm
Weight - 51.5 kgs
Investigations :
Hb - 8.3 gm/dl
TC - 2,800 cells/cumm
Pcv - 24.8 vol%
Mcv - 76.5 fl
Mch - 25.6 pg
Rbc - 3.24 millions/cumm
Plt - 1 lakh/cumm
Reticulocyte count - 0.6
Corrected RC count - 0.3
ASSESSMENT :
Ascitis (exudative type) under evaluation
? Pancytopenia under evaluation (hypoproliferative marrow)
PLAN OF CARE :
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
DAY 2
DAY 1
SOAP NOTES :
SUBJECTIVE :
Pedal edema decreased
Appetite decreased
OBJECTIVE :
Temperature - afebrile
BP - 150/100 mm hg
PR - 86 bpm
RR - 16 cpm
SPO2 - 98 % at RA
31/08/21
AG - 80 cm
Wt - 50 kgs
ASSESSMENT :
Ascitis (exudative type) under evaluation
PLAN OF CARE :
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
DAY 3
SOAP NOTES :
SUBJECTIVE :
Pedal edema decreased
Appetite improved
OBJECTIVE :
Temperature - afebrile
BP - 130/80 mm hg
PR - 82 bpm
RR - 16 cpm
SPO2 - 98 % at RA
1/09/21
AG - 79 cm
Wt - 49.5 kgs
ASSESSMENT :
Ascitis (exudative type) ? Tubercular ascitis
? Pancytopenia under evaluation (hypoproliferative marrow)
PLAN OF CARE :
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. Syp ARISTOZYME 15 ml PO/TID
6. Daily AG and weight monitoring
7. Bp charting 6th hourly
DAY 4
SOAP NOTES :
SUBJECTIVE :
Pedal edema resolved
Appetite improved
OBJECTIVE :
Temperature - afebrile
BP - 150/100 mm hg
PR - 80 bpm
RR - 16 cpm
SPO2 - 98 % at RA
2/09/21
AG - 78.5 cm
Wt - 49.3 kgs
ASSESSMENT :
Ascitis (exudative type) ? Tubercular ascitis
PLAN OF CARE :
1. Fluid restriction <1 lt/day
2. Salt restriction < 2g/day
3. Tab LASIX 40 mg /PO/BD
4. Syp ARISTOZYME 15 ml PO/TID
5. Daily AG and weight monitoring
6. Bp charting 6th hourly
DAY 5
SOAP NOTES :
SUBJECTIVE :
Pedal edema resolved
Appetite improved
OBJECTIVE :
Temperature - afebrile
BP - 140/90 mm hg
PR - 82 bpm
RR - 16 cpm
SPO2 - 98 % at RA
GRBS - 153 mg/dl
3/09/21
AG - 78 cm
Wt - 49 kgs
ASSESSMENT :
Ascitis (exudative type) ?
Tubercular ascitis
PLAN OF CARE :
1. Fluid restriction <1 lt/day
2. Salt restriction < 2g/day
3. Tab LASIX 40 mg /PO/BD
4. Daily AG and weight monitoring
5. Bp charting 6th hourly
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