General Clinics - 2

Parvathy PremchandranAditi SinghDevi Dileep

Vimala ColacoChaitra AC

Personal Data

• Patient name - Naveen Kumar• Age- 8 years• Address -Sakleshpura, Hassan District• Informant- Mother(Reliable)• Date of admission - 20/7/12• Mothers name and education- Shobha

(Illiterate)• Fathers name and education- Chandra (3rd)

Presenting Complaints

• Abdominal Distension since 1 Month• Loss of appetite since 1 month

History of presenting illness

• Abdominal Distension since 1 month• Onset insidious, gradual progression• Uniform distension• Not associated with facial puffiness or pedal

edema• No H/o pain abdomen, fever• Associated with loss of appetite • No H/o yellowish discoloration of sclera or urine

• No H/o Reduced urine output• No H/o orthopnoea, PND • No H/o cough with expectoration, evening rise of

temperature• No H/o Vomiting, hemetemesis or malaena• No H/o bleeding tendencies• No H/o blood transfusions• No H/o Constipation or diarrhoea• NoH/o Lethargy, drowsiness• No H/o altered sensorium, altered sleep wake

cycle

Past History

• No similar complaints in the past• No H/o contact with TB• No H/o Jaundice• 5 months back, patient was admitted for

swelling of right foot associated with fever and some procedure was done

• Birth Order- 2nd

• Age at pregnancy - 27 years• 1st trimester-Regular ANCs, No H/o fever with

rash, irradiation, drug intake, alcohol intake• 2nd trimester- No history suggestive of

PIH/GDM/APH. T.T injection taken• 3rd trimester- No history suggestive of

PIH/GDM/APH

Antenatal History

Natal and postnatal history

• Spontaneous onset of labour, FTNVD at home unattended by a trained dai

• Baby cried immediately• Birth weight not known• Breastfeeding initiated within 1 hour • Meconium and urine passed within 24hrs

Immunization History

• 9th month- Measles and Vit A not given• 5th year- DT Booster not given• Rest all given as per NIP

Development History• Appropriate for age• Studies in 2nd std

Dietary History• Complimentary feeding started at 1 month• Breastfeeding continued till 18 months

Calories(kcal) Protiens(g)

Breakfast 370 9.8

Lunch 300 9

Snacks 160 3.8

Dinner 275 5

Total 1105 27.6

Expected 1580 28.8

Deficit 475 1.2

Family history

• Non consanguineous marriage• No of members-5• No h/o similar complaints • No h/o jaundice in family• No h/o TB/congenital defects in the family• Upper lower socioeconomic status

Summary

• 8 yr old male child came to RAPCC with progressive abdominal distension and loss of appetite since 1 month. His development is appropriate for age. He has not received measles and DT booster. His calorie is deficient in 475 kcal and protein by 1.2g

Ascites

cardiac

No pedal edema

renal

no facial puffines

hepatic

Abdominal distension

nutritional

No generalized

edema

Abdominal distention

Ascites gaseous distention faecal retention acute acute chronic peritoneal hemorrhagepancreatitisinfarcted/perforated bowel

Examination

General physical examination• No pallor, icterus, clubbing, cyanosis,

lymphadenopathy, pedal oedema Head to toe• Oral cavity hygiene is good• Upper central incisors absent• Numerous pigmented elevated papule like lesions

on the finger pulps of Rt hand• 2 by 2 cm scar healed by sec intention present on

the dorsum of Rt foot.• No signs of liver cell failure

Vitals Afebrile during examinationPulse-88 beats/min regularRespiratory rate-38 cycles/minBP-100/80 mm hg Rt arm supineJVP not raised

Anthropometry Weight for ageObserved-20.8kgExpected-24kg (3-10th percentile)Height for ageObserved-116cmExpected-125cm(<3rd percentile)Weight for height Normal

SYSTEMIC EXAMINATION

PARVATHY PREMCHANDRAN080201122

PER ABDOMEN

On Inspection

•Shape – grossly distended•Umbilicus - pushed down, everted & transversely stretched•Flanks – full•Corresponding quadrants move equally with respiration•No visible pulsations or visible peristalsis•Skin – tense & shiny•Scar – a circular scar healed by secondary intention around the umbilicus (branding)•Dilated veins – thin veins over the costal margin•Hernial orifices appear to be normal•Genitalia - normal

On Palpation•Local rise of temperature & tenderness – absent•Guarding & rigidity – absent•Liver - palpable 8cm below the right costal margin non tender firm in consistency sharp lower border smooth surface•No other organomegaly•Abdominal girth - 62cm

On Percussion•Liver dullness – right 5th intercostal space•Liver span – 12cm•Fluid thrill – present

On Auscultation•Bowel sounds – not appreciated

Respiratory system examination

Examination of upper respiratory tract

•Nose •Para nasal sinuses normal •Pharynx

Examination of lower respiratory tract

On inspection•Trachea - deviated to left•Shape of chest – B/L symmetrical, elliptical in cross section•Movement of chest – decreased on right side•No venous pulses in the neck•No scars, skin lesions, swellings

On Palpation

•Local rise of temperature/tenderness – absent•Trachea – deviated to left•Cardiac impulse – left 5th intercostal space, lateral to mid clavicular line•Chest expansion – decreased on right side

On Percussion

•Resonant – B/L in all areas except for -•Dull note – right axillary and infra axillary area

•On Auscultation

•Breath sounds – vesicular B/L•Intensity – decreased on the right axillary & infra axillary area

Examination of cardiovascular system

•Apex beat – left 5th intercostal space lateral to mid clavicular line•On auscultation – S1 & S2 heard

Examination of central nervous system

•No abnormality detected

Differential diagnosis

Vimala Colaco

Ascites

• Hepatic Cirrhosis Lysosomal storage disease Wilson’s disease • Infectious Tuberculosis • Neoplastic Lymphoma Neuroblastoma

Cirrhosis

• Inherited metabolic liver disease Wilson’s disease Hemochromatosis alpha 1 antytrypsin deficiency• Chronic viral hepatitis• Billiary cirrhosis primary billiary cirrhosis primary sclerosing cholangitis

• Miscellaneous Eosinophilic ascites Chylous ascites Hypothyroidism

On examination- Ascites with hepatomegaly

• Hepatic Cirrhosis Lysosomal storage disease Wilson’s disease • Infectious Tuberculosis • Neoplastic Lymphoma Neuroblastoma

InvestigationsChaithra A C080201350

HEMATOLOGICAL INVESTIGATIONS

• Haemoglobin

• Total count and Differential count

• ESR

• Platelet

• Blood grouping

• Hemoglobin 20TH July-15.5g/dL

29th July-14.9g/dl• Counts

Total count- 15,800/cc• Platelets

1,89,000/cc• Blood group

B positive

Biochemical investigation

• Liver function test • Serum ceruloplasmin • Urine copper excretion • Electrolyte• Serum urea and creatinine • Blood sugar

LIVER FUNCTION TEST

Total Bilirubin - 0.4mg/dL (0.2-1.2mg/dL) Direct Bilirubin - 0.04mg/dL (upto 0.3mg/dL) SGPT - 18U/L ( 5-40 U/L) SGOT - 36 U/L (15-55U/L)

ALP - 137U/LTotal protien - 6.9 g/dl (6-8g/dl)Albumin - 4.4g/dl (3.5-5.5/dl)

PT - 21.5 (18-22s)INR - 1.6

• ELECTROLYTES Na+ --139meq/L

(136-149meq/L) K --4.2meq/L (3.5-5.3meq/L) Cl- --103.3meq/L (98-111meq/L) HCO3

- --18.6 meq/L (23-27meq/L)

• Urea -13mg/dl (5-18mg/dl)• Creatinine -0.4mg/dl (0.3-0.7mg/dl)• Serum ceruloplasmin-32.8mg/dl (15-30mg/dl)• Blood sugar -76mg/dl

Investigations for tuberculosis

• Sputum AFB (negative )

• Mantoux test (negative )

Radiological Investigation

• Ultrasound abdomen

• Chest X RAY

• Doppler

Ultrasound

• Hepatomegaly 13cm

• Gross ascitis

• Pleural effusion on right side

• Portal vein is normal

• Liver biopsy – to confirm the diagnosis

• Ascitic fluid tap ( evaluated for cell count with differential, albumin level and serum ascites albumin gradient , total protein, and culture)

• Depenicillamine challenge test

• Serum serum-ascites albumin gradient (SAAG) : • is calculated by subtracting the ascitic fluid albumin

value from the serum albumin value

• The SAAG is the best single test for classifying ascites into portal hypertensive (SAAG >1.1 g/ dL) and non–portal hypertensive (SAAG <1.1 g/dL) causes.

• The accuracy of the SAAG results is approximately 97%

• Preferably the serum and ascitic fluid specimens should be obtained simultaneously.

• A high gradient is associated

• diffuse parenchymal liver disease • occlusive portal and hepatic venous disease, • liver metastasis and• hypothyroidism.

Limitations of using SAAG • (a) the gradient may be falsely low if the patient

with cirrhosis has a serum albumin level <1.1 g/dL, and also in disease state of hypergammaglobulinemia (>5 g/dL)

• b) errors may occur if the albumin assay is inaccurate the samples are not withdrawn at relatively same time, and if the patient is in shock

• (c) a falsely high value in chylous ascites , as lipid fractions tend to interfere with laboratory determination of albumin.

Management

Principles

• Mobilization of ascitic fluid is accomplished by creating a negative sodium balance until ascites has diminished or resolved

• Restriction of dietary sodium [2meq/kg/day]and administration of diuretics.

resistant large-volume paracentesis

• Transjugular intrahepatic portosystemic shunting (TIPS)

• Orthotopic liver transplantation

Diuretics

• Spironolactone- cirrhotic ascites• Furosemide

Aim reduce body weight by 0.5-1% /day

Albumin supplementation

• 25% albumin 1 g/kg IV up to 3 times per day until serum levels are >2.5 g/dL.

Therapeutic paracentesis

• Tense ascites, non-responsive to diuretics• 118 ± 56 mL/kg at a time• iv albumin 1g/kg

Spontaneous bacterial peritonitis

• Infection of ascitic fluid without evidence of an abdominal source

• Escherichia coli , methicillin-resistant Staphylococcus aureus

• Diagnosis – paracentesis/ ascitic fluid culture• Treatment – 3rd gen cephalosporins-

cefotaxime 5 days

Wilson’s disease

• Penicillamine[ 10mg/kg/day max 1g/day]• Pyridoxine [50mg/week]• Zinc [25-50mg daily before meals]• avoidance of Cu rich food• Liver transplantation