ACUTE ON CHRONIC DECOMPENSATED LIVER DISEASE, NORMOCYTIC NORMOCHROMIC ANEMIA [HYPOPROLIFERATIVE] WITH ANEMIA OF CHRONIC DISEASE HRS-CHRONIC KIDNEY DISEASE? DIABETIC NEPHROPATHY WITH ?PORTO PULMONARY HTN

Case History and Clinical Findings 

C/O ABDOMINAL DISTENSION SINCE 4 MONTHS ON AND OFF SHORTNESS OF BREATH SINCE 4MONTHS

 HISTORY OF PRESENTING ILLNESS

PATIENT WAS APPARENTLY ASYMOTOMATIC 4 MONTHS AGO THEN HE STARTED C/O ABDOMINAL DISTENSION WHICH WAS DISTENSION WHICHWAS INSIDIOUS IN ONSET AND GRADUALLY PROGRESSIVE SINCE 1 MONTH ABDOMINAL DISTENSION IS PROGRESSIVE IN NATURE FOR WHICH HE VISITED GANDHI HOSPITAL AND WAS DIAGNOSD AS ALD WITH PORTAL HTN WITH DECOMPENSATED LIVER LIVER DISEASE WITH HEPATIC ENCEPHALOPATHY GRADE 1 WITH RT PLEURAL EFFUSION -MILD.PEDAL EDEMA SINCE 4 MONTHS INSIDIOUS IN ONSET GRADUALIIY PROGRESSIVE ,RELIEVED AT NIGHT ,AGGRAVATED IN THE MORNING [PITTING EDEMA] -SOB DUE TO ABDOMINAL DISTENSON , PRESENT EVEN ON REST ORTHOPNEA AND PND PRESENT NO CHEST PAIN,PALPITATION. C/O DECREASED URINE OUTPUT SINCE 1 MONTH PATIENT IS ON FOLEYS CATHETER SINCE THEN-K/C/O DM 2 SINCE 15 YEARS-OPERATED FOR ILIOPSOAS ABSCESS [10MONTHS AGO] 

TREATMENT HISTORY

INJ.MIXTARDBD FOR DM2 SURGERY FOR ILIOPSOAS ABSCESS PERSONAL HISTORYPERSONAL HISTORY: DIET-MIXED APPETITE -NORMAL BOWEL AND BLADDER - REGULAR SLEEP-ADEQUATE ADDICTIONS- REGULAR INTAKE SINE 15 YEARS ,10 DATS AGO PATIENT CONSUMED ALCHOL CONTINOUSLY ALLERGIES- NONE 

FAMILY HISTORY:

 INSIGNIFICANT 

GENERAL EXAMINATION: 

PATIENT IS CONSIOUS ,COHERNT ,COPERATIVE NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY 

VITALS: TEMP-AFEBRILE BP- 110/70MMHG RR-18CPM GRBS-125 MG/DL SPO2-99% AT ROOM AIR 

SYSTEMIC EXAMINATION:

CVS-S1 S2 HEARD NO MURMURS CNS-NAD RS-BAE+ NVBS

 P/A -DISTENDED,SOFT NON TENDER,NO GUARDING,NO RIGIDITY, HERNIAL ORIFICES NORMAL.

 COURSE IN THE HOSPITALPATIENT 

IS A KNOWN CASE OF CHRONIC DECOMPENSATED LIVER DISEASE SINCE 4 MONTHS WITH ASCITES .HE IS ON REGULAR MEDICATION FOR SAME SINCE 4-5 DAYS THE ASCITES HAS AGGRAVATED AND PATIENT CAME FOR FURTHER EVALUATION.USG ABDOMEN REVEALED GROSS ASCITES AND CIRRHOSIS OF LIVER.ON THOROUGH CLINICAL,LABORATORY AND RADIOLOGICAL INVESTIGATION PATIENT HAS GROSS ASCITES OF 4-5 LITRES. THE WEIGHT OF PATIENT WAS 69KGS AND ABDOMINAL GIRTH WAS 89 CMS.DIAGNOSTIC ASCITIC TAP DONE.-SHOWED HIGH SAAG AND LOW PROTEIN.THERAPEUTIC TAP OF 700ML DONE.INJ.ALBUMIN 20 PERCENT GIVEN OVER 1 HOURINITIALLY HAD LOW URINE OUTPUT AFTER ADDING LOW DOSE SPIRONOLACTONE PATIENTS URINE OUTPUT IMPROVED. NEPHROLOGY OPINION TAKEN AND DIAGNOSED AS CKD.ADVISED FOR CONSERVATIVE MANAGEMENT . TREATMENT: FLUID RESTRICTION LESS THAN 2.5 LIT/DAY TAB.NODOSIS 500MG PO BD TAB.OROFER XT PO OD TAB.SHELCAL 500MG PO OD DERMATOLOGY OPINION TAKEN FOR DIFFUSE XEROSIS OVER BILATERAL FOREARM.MULTILE HYPERPIGMENTENTED MACULES NOTED ON PALMS ALONG WITH ITCHING WAS DIAGNOSED AS PRURITIS SECONDARY TO CHRONIC LIVER DISEASE.ACQUIRED DICTHYOSIS.ADVICED LIQUID PARAFFIN BD FOR 2 WEEKS.OPHTHALMOLOGY OPINION TAKEN FOR DIABETIC RETINOPATHY CHANGES. IMP:RIGHT EYE NPDR LEFT EYE PDR NOTED ADVICED FOR GLYCEMIC CONTROL AND REVIEW TO OPD ON THURSDAY FOR RETINA SPECIALIS ON 30/05/2023 WEIGHT:71 KG ABDOMINAL GIRTH:92 CM AFTER TAP ----. 89CM ,WT -----.68KG. 2.5 LIT ASCITIC TAP DONE AND INJ.ALBUMIN 20 PERCENT GIVEN OVER 1 HR AND SYMPTOMS OF SOB AND ABDOMINAL DISCOMFORT REDUCED.PRBC TRANSFUSION DONE I/V/O SEVERE ANEMIA HB:6GM/DL.AFTER TRANSFUSION HIS HB WAS 8.7GM/DL.GASTROENTEROLOGY OPINION TAKEN.ADVICED LARGE VOLUME PARACENTESIS ALONG WITH 2 ALBUMIN TRANSFUSION ON DAY OF PARACENTESIS REFERRED TO HIGHER CENTER-- PATIENT AND PATIENTR ATTENDERS HAVE BEEN EXPLAINED ABOUT THELARGE VOLUME PARACENTESIS ALONG WITH 2 ALBUMIN TRANSFUSION ON DAY OF PARACENTES NEED FOR LIVER TRANSPLANTATIO REFERRAL ,AS THE PATIENT IS AN IDEAL CANDIDATE FOR LIVER TRANSPLANTATION AS ADVISED BY THE GASTROENTEROLOGIST AND THE SAME HAS BEEN EXPLAINED TO THE PATIENT AND PATIENT ATTENDER .AND WAS ADVISED TO MEET THE LIVER TRANSPLANTATION TEAM

 Investigation

 HAEMOGRAM 28/4/23, 29/4/23 30/4/23 01/5/23 HB:6.0 ,6.1, 5.9, 8.7, TLC:4700, 4800, 4500, 6300 PLATELET 1.65L 1.51L 1.88L 2.94 PCV:18.7 18.2, 18.2 26.1 ASCITIC FLUID - SUGAR - 104 PROTEIN - 1.2 LDH - 140 CELL COUNT - 50CELLS/CUMM , 100% LYMPHOCYTES AND CLEAR. CYTOLOGY REPORT SPECIMEN : ASICTIC FLUID CYTOLOGY MICROSCPY: CYTOMEAR STUDIED SHOWS SCATTERED LYMPHOCYTES FEW MESOTHELIAL CELLS AGAINST PROTEINACEUS BACKGROUND IMPRESSION: NEGATIVE FOR MALIGNANCY 2D ECHO: EF-60% MILD TR ;TRIVIAL MR ;NO AR NO RWDA ,NOAS/MS GOOD LV SYSTOLIC FUNCTIUON DIASTOLIC DYSFUNCTION ,NO PAH

 Treatment Given

TAB.SPROINOLACTONE 25MG/PO/OD TAB.RIFAGUT 550MG PO/BD 

TAB.UDILIV 300MG PO/BD 

SYP.LACTULOSE 15ML PO TID TAB.LASILACTONE 5/25 PO/OD 

SYP. HEPAMERZ 15ML PO/BD 

TAB PAN 40 MG PO/OD BBF

 FLUID RESTRICTION (2L/D) 

SALT RESTRICTION (2G/D) 

IV FLUIDS NS @ OUTPUT +30 ML/HR PROTEIN POWDER 2TBSPS IN 1 GLASS OF WATER /PO/TID

 INJ.VIT K IM 

Diagnosis

 ACUTE ON CHRONIC DECOMPENSATED LIVER DISEASE, NORMOCYTIC NORMOCHROMIC ANEMIA [HYPOPROLIFERATIVE] WITH ANEMIA OF CHRONIC DISEASE HRS-CHRONIC KIDNEY DISEASE? DIABETIC NEPHROPATHY WITH ?PORTO PULMONARY HTN 

Advice at Discharge

 REFERRED TO HIGHER CENTER-- PATIENT AND PATIENTR ATTENDERS HAVE BEEN EXPLAINED ABOUT THE NEED FOR LIVER TRANSPLANTATION REFERRAL ,AS THE PATIENT IS AN IDEAL CANDIDATE FOR LIVER TRANSPLANTATION AS ADVISED BY THE GASTROENTEROLOGIST AND THE SAME HAS BEEN EXPLAINED TO THE PATIENT AND PATIENT ATTENDER .AND WAS ADVISED TO MEET THE LIVER TRANSPLANTATION TEAM