Karaganda medical university

Department of Internal disease no.1

Submitted by Submitted to:

Ankur Kulhar Bodaubay Roza .
Group no. 4021

Case Study:

Patient Information: (passport information )

Name: Shabalina olga

Room No.: 1
Date of Birth: 5/Oct/1970
Age: 54
Gender: Female
Profession: Teacher
Nationality: Tatarine
Outpatient Department: 26/01/2024 (10:16)
Hospital: 26/01/2024

Complications:
Shortness of breath
Weakness
Fever
Enlarged of abdomen
Jaundice/yellow skin
History of symptoms last 1 month
Ascites
Lot of intake water

Medical history

Began experiencing fatigue and mild jaundice in last 1 month.

By 1 month ago, he noticed a decrease in appetite and a slight
swelling in his abdomen. Concerned about these symptoms, he
visited his primary care physician.
Following initial assessments and blood tests, his doctor referred
him to a gastroenterologist, suspecting liver-related issues. after
undergoing further testing, including a liver biopsy, She was
diagnosed with liver cirrhosis.
Medications Prescribed- Spironolactone (25 mg daily):
Prescribed to manage fluid retention and swelling.
Furosemide (40 mg daily): Prescribed in combination with
spironolactone to enhance its effectiveness.
Vitamin E (800 IU daily): Recommended as an antioxidant to
help with liver health.

Patient history:-
Tub infection disease absent. – She has no history of
tuberculosis infection
Hereditary information absent- No significant hereditary
information that could be contributing to her liver condition.
Ginecology history pregnancies menstruation cycle – Her
gynecological history reveals a normal course of pregnancies
and menstruation cycles.
Chronical diseases – she reports no chronic diseases and has
never undergone hemotransfusion therapy.
Injuries and Surgery operation - 3 years ago history of
umbilicus surgery.

Physical examination
Percussion and Oscillation:-
Percussion findings involve tapping or striking the body to elicit
sounds or vibrations that can provide information about the
underlying structures. While specific percussion findings weren't
provided in the case study . Oscillatory findings in various
systems refer to repetitive movements or patterns that can be
detected during physical examinations. While specific
oscillation findings weren’t provided in the case study
 Gastrointestinal System:
• Dullness in specific abdominal areas could indicate organ
enlargement or fluid accumulation. And also finding of
splenomegaly and Hepatocellular failure.
Abdominal oscillations during palpation may reveal tenderness
or pain in the epigastric region.
• Bowel sounds, if hyperactive or hypoactive, may be noted
during auscultation.

Respiratory System:
Percussion the pulmonary sound is dulled on the right. Resonant
percussion sounds over lung fields are normal, while dullness
may suggest fluid or consolidation. Patient has upper respiratory
tract infection .

Auscultation Cirrhosis can lead to the development of pleural

effusions (accumulation of fluid in the pleural space around the
lungs), especially on the right side. This might present as
diminished breath sounds at the bases of the lungs upon
auscultation.

Palpitations in the context of the respiratory system might

involve assessing for chest expansion and detecting any
tenderness or masses. However, specific findings directly related
to cirrhosis are unlikely to be palpated in the lungs.
Cardiovascular System:

Examination of the heart and large vessels no deformation was

detected of the heart region. The apical push is not visually
determined the cardiac impulse is not detected; the cardiac back
hollow is not present. Pulsation in the epigastric area, in the area
of carotid arteries and jugular fossa is not visualized.

Palpation of the heart and large vessels: the apical impulse

palpated. In the I intercostal space 1 cm inside from L
mediaclavicularis sinistra, limited, wear Pulsation in the
epigastric area is moderate BP 110/70 Pulse-78. Pulse is
rhythmic, satisfactory filling, not strained, symmetrical on both
hands.

Auscultation of the heart the tones are clear.Heart rate -78 The
rhythm of the heartbeat is correct. No noise. The friction noise
of the pleura and pericardium is absent.
Percussion of the heart: make the patient sit at 30–40-degree
angle. Tapping with the fingers is done to estimate the size of
the heart and the patient have normal. From the left side of the
chest tap the space between the ribs and tips of the middle finger
to listen for the dullness but nothing found.

Configuration of the heart is not changed. The right and left

borders of the vascular bundle are located in the II intercostal
space along the corresponding edges of the sternum. The
diameter of the beam is 5 cm.

Musculoskeletal System:
• general development of the muscular system is good. There is
no soreness when feeling the muscles, symmetrical. Rigidity of
the occipital muscles is not noted. Atrophy and hypertrophy of
individual muscles and muscle groups are not noted. Muscular
strength is good: 5 points.
Joint oscillations during range of motion assessments may reveal
stiffness or pain.
• Tremors or involuntary muscle oscillations may be present in
certain neurological conditions.

Hepatic System:
• Percussion over the liver may reveal liver borders and assess
for hepatomegaly.
• Dullness may be present if there's fluid accumulation,
indicating possible ascites.
Oscillations in liver size and consistency during palpation may
suggest hepatic abnormalities.
• Monitoring oscillations in liver enzyme levels over time can
indicate changes in liver function.

Renal System:
• The kidney area is not changed. Symptom of pounding (-)on
both sides, kidneys are not palpable,
Auscultation of the kidneys:
No direct oscillation findings are usually associated with routine
renal examinations.
Blood pressure oscillations may be monitored to assess vascular
health.
Location: Kidneys are auscultated in the flank regions, in the
area between the chest and pelvis on both sides of the spine.
Patient position: Supine with knees bent up to relax abdominal
muscles. May also try side-lying or sitting positions. Diaphragm
of the stethoscope: Used rather than the bell to pick up higher
frequency sounds. Normal findings: No renal bruit/murmur
should be audible over healthy kidneys. Only body sounds such
as gut noises may be heard.

Laboratory Parameters (Selected):

Total Protein: 81.83 g/l

Albumin: 29.13 g/l
ALT: 37.45 ME/l
AST: 91.69ME/l
Direct Bilirubin: 2.7 μmol/l
Total Bilirubin: 11.2 μmol/l
GGTP: 643.0 ME/l
Cholesterol: 6.2 mmol/l
Glucose: 7.97 mmol/l
Urea: 4.4 mmol/l
Creatinine: 79.54 μmol/l
BMI 38kg/m

Laboratory perimeters overview

Fasting Glycemic Hemoglobin

• Result: 8.2%
• Target: Less than 7.0%
• Conclusion: Elevated glycemic hemoglobin indicates
suboptimal diabetes control, requiring attention to manage blood
sugar levels effectively
 Total Protein and Albumin:
• Total Protein: 81.83 g/l
• Albumin: 29.13g/l
• Conclusion: Adequate total protein and albumin levels suggest
good nutritional status and liver function.

Liver Enzymes (ALT, AST) and Bilirubin:

• ALT: 37.45 ME/l
• AST: 91.69 ME/l
• Direct Bilirubin: 2.7 μmol/l
• Total Bilirubin: 11.2 μmol/l
• Conclusion: Elevated ALT and AST levels, along with
increased bilirubin, may indicate liver dysfunction.

GGTP and Cholesterol:

• GGTP: 643.0 ME/l
• Cholesterol: 6.2 mmol/l
• Conclusion: Elevated GGTP and cholesterol levels may
suggest potential liver and cardiovascular health concerns.

Glucose, Urea, and Creatinine:

• Glucose: 7.97 mmol/l
• Urea: 4.4 mmol/l
• Creatinine: 79.54 μmol/l
 • Conclusion: Elevated glucose levels indicate suboptimal
diabetes control, while normal urea and creatinine levels suggest
stable kidney function.

Hepatitis B and C Status:

• HBsAg: Negative
• Antibodies to Hepatitis C: Negative
• Conclusion: The patient shows no evidence of current
hepatitis B or C infection.

Urine Analysis (Total α-amylase, Glucose, Protein):

• Total α-amylase in urine: 195.3 mg/draw
• Glucose in urine: 0.00 mmol/l
• Protein in urine: 0.000 g/d
• Conclusion: Elevated total α-amylase may indicate potential
renal and metabolic issues.

Urine Characteristics (Density, Color, Transparency):

• Relative Density in urine: 1005
• Color: Light yellow
• Transparency: Transparent
• Conclusion: Normal urine characteristics, suggesting no
significant renal abnormalities.

Blood Parameters (Hemoglobin, RBC, WBC, Platelets):

• Hemoglobin: 12.6 g/l
 • RBC: 4.15 /l
• WBC: 3.54/l
• Platelets: 162 /l
• Conclusion: Blood parameters are within the normal range,
indicating stable blood composition.

Glycosylated Hemoglobin and Glycemic Profile:

• Glycosylated Hemoglobin (HGB): 8.2% (25/01/2024)
• Glycemic Profile: Varied glucose levels over multiple days
• Conclusion: Elevated HGB indicates the need for improved
long-term glucose control.

Instrumental Studies:

1 Ultrasound- Basic imaging modality for liver assessment.

Can detect signs of cirrhosis, including liver surface nodularity
and changes in liver size.
2. Computed Tomography (CT) Scan- detailed images of the
liver and can identify liver abnormalities, ascites, splenomegaly,
and potential complications like HCC.
3 Magnetic Resonance Imaging (MRI)
Diagnosis: Liver cirrhosis,
Non-alcoholic cirrhosis is a late stage of scarring (fibrosis) of
the liver caused by many forms of liver diseases and conditions,
such as hepatitis. Each time your liver is injured, it tries to repair
itself. In the process, scar tissue forms. As the cirrhosis
progresses, more and more scar tissue forms, making it difficult
for the liver to function (decompensated cirrhosis). The
progression from a healthy liver to cirrhosis may take years and
can be slowed or stopped if diagnosed and treated early.
Causes – Chronic viral hepatitis (hepatitis B, C, and D),
Nonalcoholic fatty liver disease (NAFLD), Autoimmune
hepatitis, Bile duct diseases, such as primary biliary cholangitis
(PBC) and primary sclerosing cholangitis (PSC).
Risk Factors:-
Factors that may increase your risk of non-alcoholic cirrhosis
include:
Obesity
Type 2 diabetes
Metabolic syndrome
High cholesterol and high triglycerides
Family history of liver disease
Certain genetic conditions
Chronic hepatitis infection
Autoimmune diseases
Symptoms:-
Cirrhosis symptoms may not appear until the liver is
significantly damaged. When symptoms do appear, they may
include:
Fatigue and weakness
Loss of appetite
Weight loss
Nausea
Jaundice (yellowing of the skin and eyes)
Itchy skin
Fluid accumulation in the abdomen (ascites)
Swelling in the legs
Bruising and bleeding easily
Spiderlike blood vessels on the skin
Redness in the palms of the hands.

Medication Overview
Prescribed Medicines

Urodietsya

Generic Name:Urodietsya
Dosage: 250mg, Capsule
Administration: Oral
Prescription:
25,000 IU (2 times/day for 1 day)
25,000 IU (3 times/day for 7 days)

Urcodex

Generic Name: Urcodex

Dosage: 250 mg, Capsules enteric soluble
Administration: Oral
Prescription:
20 mg (1 time/day for 1 day)
20 mg (2 times/day for 8 days)

Alderona
Generic Name: alderona®
Dosage: 0.5% (100mg/ml), 2 ml, Solution for injections
Administration: Intravenous (drop)
Co-administration: Sodium chloride (0.9%, 200 ml, Solution for
infusion)
Prescription: 1 time/day for 1 day

Getral

Generic Name: Protafan NM

Dosage: 1500 mg Suspension for subcutaneous administration
Administration: Subcutaneous
Prescription: 1 time/day for 5 days

Furosamide

Generic Name: furasamide

Dosage:10 mg/ml,2 ml, Solution for injection
Administration: Intramuscular
Co-administration: Diphenhydramine (1% (10 mg/ml), 1 ml,
Solution for injection)
Prescription: 1 time/day for 2 days
Flika

Generic Name: filika

Dosage: 15 mg/ml, 100 ml, Solution for infusion
Administration: Intravenous (droplet)
Prescription: 1 time/day