66 YEARS OLD MALE WITH ASCITES

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Name : K. Supriya (9th semester)

Roll number : 53 

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.

66 YEARS OLD MALE PATIENT FROM JAGATPALLY ,TODDY CLIMBER BY OCCUPATION,CAME TO OPD WITH THE FOLLOWING 

Presenting complaints :

Abdominal distension since 1 and half month 

Nausea and decreased appetite since 1 and half month 

Decreased urine output since 10 days 

Constipation since 2 days 

This 66 yr old male patient ,who is deaf and dum since birth have very good relationships with family ,which includes his wife ,3 daughters and 1 son .He is toddy tree climber by occupation .He was regular to his work since 2yrs ago and active person ,who used to wake up at 4:30 am and have tea in the morning and goes to his work and used to have lunch at 10:30 am (rice & curry) and at around 3:30 pm ,he used to have food again (rice & curry )as he goes to work after that ,he used to take tea in the evng and at around 9:00 pm ,dinner (rice&curry)

   He stopped work 2yrs ago ,from then ,he wakes up at 6:00 and have food at 10 :30 am and stopped eating at around  3:30 in the afternoon , remaining  everything is asusual as before .

    He diet is of mixed type ,occasional alcoholic and Gutkha chewer .

HOPI :

Patient was apparently assymptomatic 2 years ago ,then he noticed swelling ,which was sudden in onset and rapidly progressive for which he was operated within 4 days of onset  in choutuppal .

                Now ,he came to OPD  as he noticed abdominal distension after intake of food ,associated with nausea ,pain abdomen at epigastric region.

               So ,he reduced his daily intake of food .

 Patient attenders noticed that he is reducing body weight  .

Decreased urine output since 10 days 

Difficulty in passing stools since 2days and passing flatus .

B/L swelling of lower limbs upto ankle region ,which is of pitting type .

No H/O facial puffiness ,Shortness of breath , palpitations ,fever ,cough .

H/O fall from tree while climbing 5years ago .

Past History : 

Not a known case of diabetes , Hypertension ,Asthma , epilepsy ,TB ,CAD 

Personal History : 

Appetite : Decreased 

Diet : Mixed 

Bowel and bladder movements : Decreased urine output and constipation present 

addictions : occasional alcoholic ,Gutkha chewer ,non smoker 

allergies : No allergies 

General Examination : 

Patient is Conscious , Coherent and Co operative 

Moderately Built and Moderately Nourished .

Pallor -present 

Icterus , Cyanosis ,clubbing , lymphadenopathy - absent

Vitals : 

Temperature : afebrile 

Pulse rate : 98 bpm

Respiratory rate : 16 cpm 

Blood pressure : 120 /70 mm Hg 

SpO2 :98 % at room temperature 

Systemic Examination : 

Per abdomen: 

Shape of the abdomen : distended 

Umblicus : everted or slit shaped 

Tenderness present at epigastric and right lumbar region .

Fluid thrill : present 

Bowel sounds:  present n heard 

 No engorged veins and visible pulsations 

CVS : 

S1 ,S2 heard 

JVP : Normal 

RS: 

Bilateral Air Entry : present 

Vescicular breath sounds heard 

No crepts 

CNS : 

Higher mental functions : intact 

 Provisional diagnosis :  Peritonitis ?

Investigations : 

Ascitic tap done 

Cytology report : 

SAAG : 0.5 

Sugars :78 

Protein : 3.9 

Cell count : Tc - 1155 (corrected WBC count ) 

                     Dc - 80% lymphocytes ,20% neutrophils. 

Low SAAG with Lymphocytic predominance .

Treatment :

1. FLUID RESTRICTION 1.5-2LIT/DAY 

2. INJ. CEFOTOXIME 1g/ IV/PV 

3. TAB. LASIX 40mg/PO/BD 

4. SYRUP. LACTULOSE 15ml/PO/BD 

5. TWO EGG WHITES / DAY 

6. PROTEIN X POWDER 2 SCOOPS IN 100ml BD 

7. DAILY BODYWEIGHT AND ABDOMINAL GIRTH 

8. STRICT INPUT/OUTPUT CHARTING 

9. BLOOD PRESSURE  PULSE, SPO2 MONITORING 

10. GRBS MONITORING 8TH HOURLY 

11. INJ. METROGYL 500mg/IV/TID