1. General Clinics - 2
Parvathy Premchandran
Aditi Singh
Devi Dileep
Vimala Colaco
Chaitra AC

2. 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)

3. Presenting Complaints
• Abdominal Distension since 1 Month
• Loss of appetite since 1 month

4. 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

5. • 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

13. 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

14. Ascites
cardiac renal hepatic nutritional
No pedal no facial No generalized
Abdominal
edema puffines edema
distension

15. Abdominal distention
Ascites gaseous distention
faecal retention acute
acute chronic peritoneal hemorrhage
pancreatitis
infarcted/perforated bowel

16. Examination

17. 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

18. Vitals
Afebrile during examination
Pulse-88 beats/min regular
Respiratory rate-38 cycles/min
BP-100/80 mm hg Rt arm supine
JVP not raised

19. Anthropometry
Weight for age
Observed-20.8kg
Expected-24kg (3-10th percentile)
Height for age
Observed-116cm
Expected-125cm(<3rd percentile)
Weight for height
Normal

20. SYSTEMIC EXAMINATION
PARVATHY PREMCHANDRAN
080201122

21. 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

22. 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

23. 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

24. 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

25. 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

26. Differential diagnosis
Vimala Colaco

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

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

29. • Miscellaneous
Eosinophilic ascites
Chylous ascites
Hypothyroidism

30. On examination- Ascites with
hepatomegaly
• Hepatic
Cirrhosis
Lysosomal storage disease
Wilson’s disease
• Infectious
Tuberculosis
• Neoplastic
Lymphoma
Neuroblastoma

31. Investigations
Chaithra A C
080201350

32. HEMATOLOGICAL INVESTIGATIONS
• Haemoglobin
• Total count and Differential count
• ESR
• Platelet
• Blood grouping

33. • 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

34. Biochemical investigation
• Liver function test
• Serum ceruloplasmin
• Urine copper excretion
• Electrolyte
• Serum urea and creatinine
• Blood sugar

35. 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/L
Total 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

36. • 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

37. Investigations for tuberculosis
• Sputum AFB (negative )
• Mantoux test (negative )

38. Radiological Investigation
• Ultrasound abdomen
• Chest X RAY
• Doppler

39. Ultrasound
• Hepatomegaly 13cm
• Gross ascitis
• Pleural effusion on right side
• Portal vein is normal

41. • 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

42. • 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.

43. • A high gradient is associated
• diffuse parenchymal liver disease
• occlusive portal and hepatic venous disease,
• liver metastasis and
• hypothyroidism.

44. 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.

45. Management

46. 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

47. • Transjugular intrahepatic portosystemic
shunting (TIPS)
• Orthotopic liver transplantation

48. Diuretics
• Spironolactone- cirrhotic ascites
• Furosemide
Aim reduce body weight by 0.5-1% /day

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

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

51. 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

52. 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