52year old male with ascites
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Here is the case i have seen,
52 year old male farmer and daily wage labourer by occupation came with complaints of abdominal distension since 2 months and indigestion
weight loss and
shortness of breath(grade 2)
Constipation(since 1month)
Patient was apparently asymptomatic 2 months back then patient observed abdominal distension,insidious in onset, gradually progressive
h/o weight loss of about 5-6kgs over 2months
h/o constipation on and off since 1 month
SOB grade 2 since 2months on and off
No h/o pedal edema,facial puffiness
Urine output normal
No h/o hematemesis,malena, Yellowish discoloration of eyes
No h/o frothy urine
c/o dry cough on and off since 2months associated with generalised weakness
pt has good appetite but after eating food he said he almost always felt abdominal discomfort,belchings,SOB and used antacids very frequently.He started taking less amount of food due to abdominal discomfort since 2months
No h/o fever,burning micturation
Alcoholic since 20years(90ml daily)
smoker since 40years(1 beedi pack /day)
not a k/c/o HTN,DM,CAD,CVA ,Epilepsy
O/E
PR 82bpm
BP 80/60mmhg
RR 24/min
Temp 100F
General examination
pt is cachexic
Temporal wasting +
No pallor
No icterus
cheek bones prominent
Facial muscles wasting+
No lymphedenopathy:
JVP:normal
Biceps triceps wasting+
Anterior Ribs protruding out in parasternal area
No dilated veins
No pedal edema
Asterexis absent
CVS
s1s2+,No murmurs
RS
Ap diameter:
Transverse diameter:
BAE+
NVBS+
P/A
Shape of abdomen:
No dilated abdominal veins
shifting dullness+
fluid thrill -
Free fluid+
No hepatosplenomegaly
Bowel sounds:
CNS
HMF intact
Speech intact
No motor and sensory deficits
No signs of meningeal irritation
RBS 99mg/dl
1.Ascitic fluid cell count
Appearance: slightly reddish
Total counts 920cells/cumm
Neu 15
Lymphocytes 85
RBC 6-8/hpf
Occasional mesothelial cells
Lymphocyte predominent
2.SAAG high protein,low saag
3.Ascitic fluid LDH: 407
Tuberculous peritonitis (TP) is identified by ascites with high protein content, a low glucose and low SAAG, elevated ascitic fluid WBC count, and lymphocyte predominance. In TP, the fluid Gram stain and acid-fast stain results are rarely positive, and routine culture results are falsely negative in as many as 80% of cases. A peritoneal fluid protein level greater than 2.5 g/dL, LDH level greater than 90 U/mL, and predominantly mononuclear cell count of more than 500 cells/µL should raise the suspicion of TP, but specificity for the diagnosis is limited. Laparoscopy with visualization of granulomas on peritoneal biopsy and specific culture (which requires 4-6 wk) may be needed for definitive diagnosis.
https://www.medscape.com/answers/180234-55868/how-is-tuberculosis-peritonitis-tp-diagnosed
Diagnosis of tubercular ascites is likely
Upper Gi endoscopy:No esophageal varices
Pt was not affordable for CECT abdomen or laproscopic biopsy ,so started up on empirical ATT from 1/4/2021 ,3tabs according to weight and discharged
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