48 yr male with ascites, pedal edema since 2 months

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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

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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 :Diet:mixed
Appetite:normal
Sleep: inadequate
Bowel and bladder movements:normal
Addictions: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-->81cm



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



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

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