74year old female with abdominal distension and pedal oedema

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AMC CUBLICLE -BED 1

DOA: 11/5/23

A 74 year old female ,resident of nkp , came to the opd with chief complaints of 

Abdominal distension since 3 months 

Swelling of both lower limbs since 2 months

HOPI:

She was apparently asymptomatic 3 months ago then she developed abdominal distension,insidious in onset ,gradually progressive,aggravating on taking food ,relieving on taking mediation.

Then later she developed pedal oedema(pitting type ),insidious onset ,gradually progressive from ankle to above knee ,no aggravating factors and relieving on medication (as given by local RMP )

No h/o SOB,orthopnea,PND and decreased urine output 

No h/o abdominal pain ,constipation ,cough 

No h/o easy fatigability ,palpitations 

H/o low grade Fever +(on and off)

H/o burning micturition+

H/o weight loss is present(around 4-5 kg) since 6 months 

Past history:

K/c/o HTN and DM since 10 years ( on regular medication TEMLA-40 and METFORMIN 500mg)

H/o CVA  10-12 years ago

No h/o thyroid,TB,BA,Epilepsy 

Personal history:

Diet:mixed 

Appetite:decreased 

Bowel and bladder-regular 

Sleep -adequate

No addictions 

Family history:not significant 

General examination:

She is conscious, coherent and cooperative 

Well oriented to time ,place and person 

Vitals :

Temp: Afebrile

Bp:110/80mmofhg

PR:82bpm

RR:16cpm

Pallor :+

 Pedal edema +(bilateral pitting type ,up to ankle)

No icterus ,clubbing,cynosis,lymphadenopathy 

Local examination; 

Inspection;

Shape of abdomen;  distended

Position of umbilicus: central and inverted

No scars and sinuses are present

All quadrants are moving equally with respiration

Palpation:

No tenderness

Mild hepatomegaly is present

Percussion:

Fluid thrill present 

Auscultation:

Bowel sounds heard 

 

Systemic examination:

RS:BAE+,NVBS heard

CVS:s1,s2heard ,no murmurs

CNS:NO FND 

Provisional diagnosis: ASCITIS under evaluation 

Investigatons:

Diagnostic Ascitic tap :

 Serology :NR

Usg abdomen:

CXR:

ECG:

2decho:

12/5/23:

Fbs-109

RFT:

Ur-20

Cr-1.3

Uricacid-7.4

Ca-9.9

Po4 -2.6

Na+-140

K+-3.9

Cl-103

Hemogram:

Hb-7.4%

Tc-5,900

Plt-1.94

Pcv-25

Mcv-74.6

Mch-22

Rdw-cv: 32

Rbc-3.35

Portal Doppler:

USG abdomen :

Final diagnosis:

CHRONIC LIVER DISEASE with PORTAL HYPERTENSION (CIRRHOSIS)

Treatment:

1.Inj.lasix 40mg /IV/BD

2.Inj.optineuron 1amp/IM/OD

3.T.metformin 500mg Po/OD

4.Tab.Telma -40mg Po/OD