CASE PRESENTATION

DR.YUSRA MEMON HOUSE OFFICER MEDICAL UNIT 4 CHK 5 NOV 2013

BIODATA:
NAME SEX AGE OCCUPATION RESIDENCE MARITAL STATUS D.O.A M.O.A

AMNA FEMALE 42 years HOUSEWIFE MODEL COLON KARACHI MARRIED 24.1 .2 1 EMERGENCY

PRESENTING COMPLAINTS:
Swelling in feet for last 2 months Abdominal distension for last 1 month Shortness of breath for last 25-30 days

HOPC:
Patient is known diabetic and hypertensi e for last 3 years!Acc to her she was in her "s"al state of health 2 months ago when she de eloped bilateral swelling of feet #locali$ed and progressi e after she sprained her ankle! %he swelling lessened o er time! After 10-15 days of swelling she started de eloping abdominal distension which was progressi e in nat"re and not associated with pain# omiting#altered bowel habits#heart b"rn#bloating or malena! Patient is also complaining of dysphagia both to li&"ids and solids 15 days back which de eloped grad"ally ! She also complains of bl"rring of ision! She de eloped shortness of breadth 22 days before which was grad"al in onset #was on rest and e'ertion associated with chest tightness! (o associated P() or orthopena! *s associated with co"gh which is se ere in intensity# prod"cti e! Patient has been ha ing this problem since many years on and off!

Sys !"#$ R!%#!&'

GENERAL Weakness Fatigue Fever Decrease in body weight RESPIRATORY Cough Sputum Dyspnea CVS Palpitation Dyspnea High BP CNS Headache Change in mood ABDOMEN Difficulty in swallowing Heart burn Dec appetite bd pain

PAST HISTORY:
MEDICAL HISTORY' Hypertension and diabetes mellitus since three years history of blood transfusion twice after delivery SURGICAL HISTORY' !"cision of some swelling on left upper back ten years ago Pleural tap done four years ago Si' (+)

P E R S O N A L H I S TO RY' Sleep disturbed ppetite decreased Bowel habits normal #icturation normal ddiction none FA M I LY H I S T O R Y ' Father died due to $%B Brother hypertensive D RU G H I S TO RY $ B% $enormin &' mg ( S)S $ B% lpro" '%&mg HS since *+ years A L E R G I C H I S TO RY' Seasonal , winter , dust , perfume S O C I O E C O N O M I C H I S TO RY' #iddle class

E+("#,( #-,'
#iddle aged female patient of average height and built,dyspneic,unable to lie flat,well oriented to time and place and person% V# ()s' B%P *-'./' Pulse 01 bpm $emp 0/%-F 2.2 1/ NON*VITALS'

3, 43, C5, Cl5, D5, !336B.7 pitting8, P%erythema

3, 49P raised
7%: $H;2)<D not palpable normal

C.!s

E+ ( " # , ( # , ' INSPECTION' 2.2 1/ breaths.min%2espiration is thoraco abdominal%

Shape is normal and symmetrical = no prominent veins, pulsations or scars% Chest movements are reduced on right side% PALPATION' $rachea centrally placed, chest cavity is bilaterally symmetrical = no tenderness > e?ual movements on both sides on respiration% Dec@ breath sound at bases and on right side > e?ual vocal fermitus on both sides% pe" beat palpable at &th <CS, #C7 > is of normal character% PERCUSSION' Percussion note is stony dull AUSCULTATION' 9esicular breathing = dec@ breath sounds at bases and right side > basal crepts%

A B D O M I N A L E / A M I N AT I O N '
INSPECTION
Distended abdomen = everted umblicus, positioned in midline = no visible pulsations, scar, striae or prominent veins%

PALPATION
:on tender, tense abdomen = no rigidity , rebound tenderness or any palpable mass% :o visceromegaly

PERCUSSION:
Percussion note dull = 3ve shifting dullness and fluid thrill 3ve

AUSCULTATION
Aut sounds audible, no bruit

CVS E+("#,( #-,'

Palpable ape" beat at &th <CS, #C7% S* and S1 audible, no heart murmurs

CNS E+( " # , ( # , ' ACS *&.*&

!+#-9&, intact

S U M M A RY'
#iddle aged female having history of bilateral pitting pedal edema, abdominal distension and shortness of breath with duration of months% bdominal e"amination reveals distended abdomen ,umbilicus everted , fluid thrill and shifting dullness is positive% Chest e"amination reveals decreased breath sounds on right side and percussion note is dull crepts on right side and bases

DIFFERENTIAL DIAGNOSIS'
C):A!S$<9! C 2D< C F <7B2! CH2):<C 7<9!2 D<S! S!

L A B I N V E S T I G AT I O N S '
1&%*'%1'*C
Hb HC$ #C9 #CH #CHC $7C :!B$2)PH<7S 7;#PH)C;$!S !S<:)PH<7S #):)C;$!S P 7$!7!$S P$.<:2 (ormochromic #normocytic! /%C 1'%0/%D' C-%/ C-%+ &-'' D0E *'E &E DE *1-''' *C%1.*%1-

U/C/E:
:a F C7 B2! C2! 2BS *1& +%C 00 *& '%0 *D1

LFTs:
$%Bil SAP$ 7F PH *%+0 **'&

$otal proteins lbumin Alobulin .A ratio Hb *c

&%C */ C%& '%& +%C

SEROLOGY:
Hepatitis B Hepatitis C Brine C.S non reactive reactive no growth

CHEST XRAY P/A VIEW:

,hest 'ray show bilateral ple"ral eff"sion -ore on right side then left!

U/S ABDOMEN:
Coarse liver with irregular margins and dilated portal veins *%+ cm, thick walled gall bladder, spleenomegaly *+%C cm with dilated spleenic veins *%Ccm and varices and gross ascites% $hese findings are consistent with chronic liver disease% Bilateral moderate pleural effusion% 7eft renal cortical cysts%

WORKUP FOR CCF:

ECHO 20.10.2013 !Gection fraction &&E :ormal siHe all + cardiac chambers% :ormal siHe 79 siHe and systolic function Arade * diastolic dysfunction #ild $2% 2ight ventricle *Dmm%

WORK UP FOR CLD:

As$# #$ 1)2#3 D4R' scitic fluid glu scitic fluid prot scitic fluid $7C sitic fluid neutrophils scitic fluid lymphocyte scitic fluid 2BC *&+%'' mg.dl C'' mg.dl +' .cumm /'E 1'E 63338

S A I 6albumin concentration of serum8 5 6albumin concentration of ascitic fluid8% S A J *%* $ransudate S A K *%* !"udate

Pleural fluid glu Pleural fluid prot Pleural fluid 2BC Pleural fluid $7C Pleural fluid polymorph Pleural fluid lymphocyte

*** mg.dl 0''mg.dl 638 C''.cumm *'E 0'E

L#5. 6s $7# !7#(' 6e"udative if8 $he ratio of pleural fluid protein to serum protein is greater than '%& $he ratio of pleural fluid 7DH and serum 7DH is greater than '%Pleural fluid 7DH is greater than '%- or L times the normal upper limit for serum% Different laboratories have different values for the upper limit of serum 7DH, but e"amples include 1'' and C'' <B.l%

CLD:
disease process of the liver that involves a process of progressive destruction and regeneration of the liver parenchyma leading to fibrosis and cirrhosis%

Causes:

V#7() $(2s!s' Hepatitis B Hepatitis C Cytomegalovirus 6C#98 !pstein Barr 9irus 6!B98 T-+#$ (,3 3725s lcoholic liver disease miodarone #ethotre"ate :itrofurantoin M! (8-)#$ :on5alcoholic fatty liver disease Haemochromatosis WilsonMs Disease A2 -#""2,! utoimmune Chronic Hepatitis Primary Biliary Cirrhosis Primary Sclerosing Cholangitis O .!7 2ight heart failure

Complica io! o" ci##$osis:

P-7 () Hy9!7 !,s#-, scites Hypersplenism 6with or without splenomegaly8 7ower oesophageal varices and rectal varices Sy, .! #$ Dys12,$ #-, Hypoalbuminaemia Coagulopathy H!9( -92)"-,(7y Sy,37-"! H!9( -7!,() Sy,37-"! E,$!9.()-9( .y H!9( -$!))2)(7 C(7$#,-"( 6also called hepatoma8

Si%!s associa e& 'i $ &ia%!osis:

Clubbing Palmar erythema Spider nevi 6angiomata8 Aynaecomastia Feminising hair distribution $esticular atrophy Small irregular shrunken liver naemia Caput medusae 6recanalisation of the umbilical vein86Distended abdominal veins8

Signs asso ia!"# $i!% #" o&'"nsa!ion:

Drowsiness 6encephalopathy8

Hyperventilation 6encephalopathy8

#etabolic Flap. steri"is 6encephalopathy8

4aundice 6e"cretory dysfunction8

scites 6portal hypertension and hypoalbuminaemia8

7eukonychia 6hypoalbuminaemia8

Peripheral oedema 6hypoalbuminaemia8

Bruising 6coagulopathy8

cid5base imbalance, most commonly respiratory alkalosis

Signs asso ia!"# $i!% a"!io(og):

DupuytrenMs contracture 6 lcohol8 Parotidomegally 6 lcohol8

Hepatomegaly 6alcohol, : F7D, Haemochromatosis8 Fayser5Fleisher 2ings 6WilsonMs8 <ncreased pigmentation of the skin 6Haemochromatosis8

Peripheral neuropathy 6 lcohol and some drugs8

Cerebellar signs 6alcohol and WilsonMs disease8

Signs of 2ight Heart Failure

RISK FACTORS:
Health care professionals who are e"posed to body fluids and infected blood <ndividuals who get multiple tattoos and body piercing Certain prescription medications !"cessive alcohol use Having high levels of fat in the blood Sharing infected needle and syringes )besity Having unprotected se" and multiple se" partners Working with to"ic chemicals without wearing safety clothes

ASSESSMENT:
#odel for !nd5Stage 7iver Disease Child5Pugh score

MODEL FOR END STA*E LIVER DISEASE:

#!7D uses the patientMs values for serum bilirubin, serum creatinine, and the international normaliHed ratio for prothrombin time 6<:28 to predict survival #!7D I C%D/N7n serum bilirubin 6mg.d78O 3 **%1N7n <:2O 3 0%&DN7n serum creatinine 6mg.d78O 3 -%+C
<n interpreting the #!7D Score in hospitaliHed patients, the C month mortality is@ N-O +' or more C'PC0 1'P10 *'P*0 K0 D*%CE mortality &1%-E mortality *0%-E mortality -%'E mortality *%0E mortality

C%i(#+',g% s o-":

T-"a!&"n!:
$he treatment of chronic liver disease depends on the cause% While some conditions may be treated with medications, others may re?uire surgery or a transplant% $ransplant is re?uired when the liver fails and there is no other alternative%

A) !7,( #%! C(7!' Because many chronic liver disorders have no cure, many people have been turning to alternative health care% Herbal supplements are widely used by many people with chronic liver disease :one of these herbs have ever been tested in randomiHed clinical trials and no one knows whether they work% So if you decide to use herbs for your chronic liver disease, read about the herb, know your disorder and talk to your physician% Some common herbs known to be potentially harmful in liver disease include black cohosh, mahuang, chaparral, comfrey,

P-"."n!ion:
Some chronic liver diseases cannot be prevented but one can reduce the risk by adopting the following measures@ Do not drink e"cessive alcohol% void high risk behaviour% <f you do use intravenous drugs, do not share needles or syringes% Safe se" and avoid multiple se" partners% <f you plan to have tattoos or have your body pierced, choose a place which has a reputation for cleanliness and safety% Aet vaccinated against hepatitis and B% it is highly recommended that one get vaccinated against hepatitis B% $his chronic infection is highly contagious and one of the complications is liver cancer%

Do not use multiple medications or illicit drugs unwisely% :ever mi" alcohol with medications% lways talk to your physician about your medications and get your liver enHymes checked to make sure that the liver is functioning fine% <f you have any member of the family of friend who is sick, avoid contact with blood or bodily fluids% #any infections can be transferred through body fluids include H<9, hepatitis and evenherpes% Do not make it a habit of sharing personal care products with anyone, even household members% <f you work in an environment where there are chemicals, wear a mask% $ake protective measures when spraying weed killers, insecticides or using other to"ic chemicals% <f you work with haHardous chemicals, change clothes before you go home% <f you work in the garden and use chemicals, wear long sleeve shirts, gloves and a hat% !at healthy e"ercise and keep your weight down% )besity is a well known cause of chronic fatty liver disease%

C#77.-s#s T7!( "!, '

lthough there is no cure for cirrhosis of the liver, there are treatments available that can stop or delay its progress, minimiHe the damage to liver cells, and reduce complications% $he treatment used depends on the cause of cirrhosis of the liver% For cirrhosis caused by alcohol abuse, the person must stop drinking alcohol to halt the progression of cirrhosis% If a perso has hepa!i!is, the doctor may prescribe steroids or antiviral drugs to reduce liver cell inGury% For people "i!h cirrhosis caused by au!oi##u e diseases$ %ilso &s disease$ or he#ochro#a!osis, the treatment varies%

#edications may be given to control the symptoms of cirrhosis% !dema 6fluid retention8 and ascites 6fluid in the abdomen8 5 by reducing salt in the diet% 5 diuretics 6used to remove e"cess fluid and to prevent edema from recurring8 5 Paracentesis with or without a protein 6albumin8 infusion% 5 $ransGugular intrahepatic portosystemic shunt 6$<PS8% $his procedure can divert fluid from the abdominal cavity and may be used to treat ascites that does not respond to other forms of treatment% For S%B%P@ 5 ntibiotics, such as ciproflo"acin or cefota"ime Diet and drug therapies can help improve the altered mental function that cirrhosis can cause% 7a"atives such as lactulose may be given to help absorb to"ins and speed their removal from the intestines%

'e!a(bloc)er #edici es$ such as propranolol and nadolol% $hese medicines reduce the risk of variceal bleeding caused by portal hypertension% Beta5blockers may help lower the pressure in the portal veins, which can reduce your risk of having a first episode of variceal bleeding% $hese medicines also may be used to reduce the risk of recurrent bleeding% *asoco s!ric!or #edici es such as octreotide% $hese medicines are used to treat a sudden 6acute8 episode of variceal bleeding% $hey reduce blood flow through the portal veins by temporarily narrowing the blood vessels% E doscopic +ariceal ba di , or sclero!herapy- $hese techni?ues may be used to treat and prevent variceal bleeding in the esophagus%

DIET PLAN:
%he dietary recommendations may ary# depending on how well yo"r li er is working! *t is ery important to be "nder the care of a doctor# beca"se maln"trition can lead to serio"s problems! *n general# recommendations for patients with se ere li er disease may incl"de. /arge amo"nts of carbohydrate foods! ,arbohydrates sho"ld be the ma0or so"rce of calories in this diet! -oderate intake of fat# as prescribed by the health care pro ider! %he increased carbohydrates and fat help preser e the protein in the body and pre ent protein breakdown! Abo"t 1 gram of protein per kilogram of body weight! %his means that a 151-po"nd 230-kilogram4 man sho"ld eat 30 grams of protein per day! %his does not incl"de the protein from starchy foods and egetables! A person with a se erely damaged li er may need to eat less protein than this# and may e en be limited to small &"antities of special n"tritional s"pplements! A oid limiting protein too m"ch# howe er# beca"se it can lead to maln"trition! +itamin s"pplements# especially 5-comple' itamins! 6ed"ce how m"ch salt yo" cons"me 2typically less than 1500 milligrams per day4 if yo" are retaining fl"id!