A 38YR OLD MALE PT.WITH ABDOMINAL PAIN


Case History and Clinical Findings
C/O PAIN ABDOMEN
YELLOWISH DISCOLORATION OF EYES
ABDOMINAL DISTENSION
PEAL EDEMA SINCE ONE MONTH
HOPI :
PATIENT WAS APPARENTLY ALRIGHT 1 MONTH BACK THEN HE HAD PAIN ABDOMEN IN THE
EPIGASTRIC REGION AND UMBILICAL REGION WHICH IS TWISTING TYPE OF PAIN , NON
RADIATING , NOT AOCIATED WITH NAUSEA , VOITINGS , OR LOOSE STOOLS
ABDOMINAL DISTENSION SINCE ONE MONTH
PEDAL EDEMA SINCE 1 MONTH WHICH IS PITTING TYPE
FEVER + SINCE 1O DAYS , LOW GRADE , ONLY EVENING RISE OF TEMPERATURE
NO CHEST PAIN , SOB , PALPIATIONS .
NO MALENA , HEMATURIA , HEMATEMESIS
PAST HISTORY :
N/K/C/O DM , HTN , THYROID DIORDERS , CVA , CAD
PERSONAL HISTORY:
MIXED DIET
APPETITE IS NORMAL
BOWEL AND BLADDER - REGULAR
ADDICTIONS: ALCOHOLIC SNCE 20 YEARS [DAILY 90ML}
GENERAL EXAMINATION:
PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE
PALLOR+
 NO SIGNS OF PALLOR,ICTERUS,CLUBBING,CYANOSIS ,LYMPHADENOPATHY,EDEMA
VITALS-
TEMP- 98.5
PR- 98 BPM
RR- 18CPM
BP-110/60MMHG
SPO2- 98% AT RA
NO CHEST PAIN , SOB , PALPIATIONS .
NO MALENA , HEMATURIA , HEMATEMESIS
Investigation
HB : 7.1
PCV : 21.2
TLC : 5000
RBC : 2.04
PLATEELET COUNT : 1.5
PT : 18 SECINRV: 1.33
APTT : 35
SEROLOGY : NEGATIVE
RBS : 142
RFT :
UREA : 21
CREATININE : 0.8
2/10/23 4/10/23
NA : 136 137
K : 3.7 3.8
CL: 98 104
LFT : 2/10/23 3/10/23
TB: 3.17 2.40
DB : 1,.64 1.94
AST:58 47
ALT : 28 22
ALP :263 251
TP :6.2 6.4
ALBUMIN : 2.2 2.76
A/G : 0.55 0.76
CA IONIZED : 1.01 1.20
ASCITIC FLUID CYTOLOGY :
SHOWS PREDOMINANTLY DEGENERATED NEUTROPHILS , FEW LYMPHOCYTES ,
MESOTHELIAL CELLS IN AN PROTIACIOUS BACKGROUND
NO EVIDENCE OF ATYPICAL CELLS
ASCITIC FLUID SUGAR- 171 MG/DL
ASCITIC FLUID PROTEIN- 1.5 GM/DL
ASCITIC FLUID LDH-207 IU/L
CELL COUNT OF ASCITIC FLUID:
APPEARS CLEAR
COLOR-PALE YELLOW
TOTAL COUNT-300 CELLS/CUMM
NEUTROPHILS-70%
LYMPHOCYTES- 30%
RBC-NIL
FEW MESOTHELIAL CELLS SEEN
VOLUME - 2ML
SERUM ALBUMIN - 2.2 GM/DL
ASCITIC ALBUMIN - 0.4 GM/DL
SAAG- 1.8
Diagnosis
DECOMPENSATED CHRONIC LIVER DISEASE SECONDARY TO ALCOHOL
SUBACUTE BACTERIAL PERITONITIS
ANEMIA SECONDARY TO NUTRITIONAL ? B12 DEFICIENCY
Treatment Given(Enter only Generic Name)
1. FLUID RESTRICTION <1.5 LITRES /DAY
2. SALT RESTRICTION <2 G /DAY
3. INJ PAN 40 MG IV /OD
4. INJ CEFOTAXIME 2 GM IV /TID X 4DAYS
5.INJ VITCOFOL 2500 MG IM/OD X 4DAYS
6.TAB . LASIX 20 MG PO /BD
7.TAB.UDILIV 300 MG PO/BD
8.TAB.BENFOMET PLUS PO /BD
9.2-3 EGG WHITES /DAY
Advice at Discharge
1. FLUID RESTRICTION <1.5 LITRES /DAY
2. SALT RESTRICTION <2 G /DAY
3. TAB.PAN 40 MG IV /OD X 3 DAYS
4.TAB.TAXIM 200MG PO/BD X 3 DAYS
5.TAB.LASIX 20MG PO/BD X 1 WEEK
6.INJ.VITCOFOL (2500MG)
ALTERNATE DAY X 1 WEEK
WEEKLY ONCE X 1 MONTH
MONTHLY ONCE X 3MONTHS
7.TAB.UDILIV 300 MG PO/BD X 1 WEEK
8.TAB.BENFOMET PLUS PO /BD X 1 WEEK
9.2-3 EGG WHITES /DAY
Follow Up
REVIEW AFTER 1 WEEK WITH LFT REPORTS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.




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