All other causes cardiac, renal, hypoproteinemia ruled out because of absence of pedal oedema, facial puffiness and anasarca respectively .
General Clinics - 2 Parvathy Premchandran Aditi Singh Devi Dileep Vimala Colaco Chaitra 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
Antenatal History• 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
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
Ascitescardiac renal hepatic nutritional No pedal no facial No generalized Abdominal edema puffines edema distension
General physical examination• No pallor, icterus, clubbing, cyanosis, lymphadenopat hy, 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
VitalsAfebrile during examinationPulse-88 beats/min regularRespiratory rate-38 cycles/minBP-100/80 mm hg Rt arm supineJVP not raised
AnthropometryWeight for ageObserved-20.8kgExpected-24kg (3-10th percentile)Height for ageObserved-116cmExpected-125cm(<3rd percentile)Weight for heightNormal
PER ABDOMENOn 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 theumbilicus (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 - 62cmOn Percussion•Liver dullness – right 5th intercostal space•Liver span – 12cm•Fluid thrill – presentOn Auscultation•Bowel sounds – not appreciated
Respiratory system examinationExamination of upper respiratory tract•Nose•Para nasal sinuses normal•PharynxExamination of lower respiratory tractOn 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 sideOn 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 heardExamination of central nervous system•No abnormality detected
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.
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