A 40 YR OLD MALE WITH CLD


Case History and Clinical Findings
CHIEF COMPLAINTS:
C/O DiSTENSION OF ABDOMEN SINCE 3DAYS
C/O SOB SINCE 3 DAYS
HOPI
PATIENT WAS APPARENTLY ASYMPTOMATIC 3 DAYS BACK THEN HE DEVELOPED
DISTENSION OF ABDOMEN SINCE 3 DAYS WHICH IS INSIDIOUS IN ONSET, GRADUALLY
PROGRESSIVE. C/O SOB SINCE 3 DAYS GRADE 3 MMRC DUE TO DISTENSION OF ABDOMEN.
NO CHEST PAIN, NO PALPITATIONS, NO VOMITING, NO LOOSE STOOLS
NO H/O ORTHOPNEA, PND
NO H/O FEVER, COUGH, COLD
NO H/O POLYURIA OR DECREASED URINE OUTPUT
NO H/O BURNING MICTURITION
H/O SIMILAR COMPLAINTS ONE MONTH BAACK AND ADMITTED IN HOSPITAL DUE TO
ICTERUS. MANAGED CONSERVATIVELY AND SYMPTOMS RELIEVED.
PAST HISTORY:
N/K/C/O DM 2, HTN, TB, EPILEPSY, CVA
PERSONAL HISTORY ;
DIET : MIXED
APPETITE : NORMAL
SLEEP : NORMAL
BOWEL AND BLADDER : REGULAR
NO ALLERGIES
SINCE 5 YEARS-SARA(COUNTRY ALCOHOL) STOPPED SINCE 2 MONTHS
FAMILY HISTORY :INSIGNIFICANT
GENERAL EXAMINATION :
PATIENT IS CONSCIOUS , COHERENT , COOPERATIVE
MODERATELY BUILT AND NOURISHED .
NO SIGNS OF PALLOR , ICTERUS , CYANOSIS , CLUBBING ,LYMPHADENOPATHY, EDEMA.
VITALS :
TEMPERATURE: 98.4F
PR - 97BPM
BP - 110/70 MMHG
RR - 18 CPM
SPO2 - 98% ON ROOM AIR
GRBS - 159 MG%
SYSTEMIC EXAMINATION :
PER ABDOMEN :
INSPECTION :
ABDOMEN IS DISTENDED
UMBILICUS IS CENTRAL
ALL QUADRANTS ARE MOVING EQUALLY WITH RESPIRATION
NO SINUSES , ENGORGED VEINS, VISIBLE PULSATIONS .
PALPATION :
NO LOCAL RISE OF TEMPERATURE
NO TENDERNESS
ABDOMINAL GIRTH 60 CM
LIVER AND SPLEEN - NOT PALPABLE
PERCUSSION :
FLUID THRILL ABSENT
SHIFTING DULLNESS PRESENT
AUSCULTATION :
BOWEL SOUNDS ARE HEARD.
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD.
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH
SOUNDS HEARD
CENTRAL NERVOUS SYSTEM: NFND
PSYCHIATRY REFERREL:
IMPRESSION: ALCOHOL DEPENDENCE SYNDROME- CURRENTLY ABSTINENT
ADVICE:
1. RELAPSE PREVENTION TECHNIQUES EXPLAINED
2. PATIENT &OD PSYCHOEDUCATED
COURSE IN THE HOSPITAL:
PATIENT CAME WITH THE ABOVE COMPLAINTS. AFTER EVALUATING HIM CLINICALLY AND
WITH APPROPRIATE INVESTIGATIONS, HE WAS FOUND TO HAVE CHRONIC LIVER DISEASE.
DIAGNOSTIC AND THERAPEUTIC ASCITIC TAP WAS DONE AND AROUND 300 ML ASCITIC
FLUID WAS DRAWN OUT. PSYCHIATRIC REFERREL WAS TAKEN IN VIEW OF ALCOHOL
DEPENDENCE AND ADVICE WAS FOLLOWED. ENDOSCOPY WAS DONE TO RULE OUT
OESOPHAGEAL VARICES. PATIENT RECOVERED SYMPTOMATICALLY AND DISCHARGED IN
STABLE CONDITION.
Investigation
19/04/23
HEMOGRAM
HB- 9.2 GM/DL
TLC- 8900CELLS/CU.MM
N/L/E/M: 62/25/3/10
PLT-1.25 LAKHS/CU.MM
USG ABDOMEN:
? CIRRHOSIS OF LIVER
BORDERLINE SPLENOMEGALY
MILD TO MODERATE ASCITIS
2D ECHO
NO RWMA. NO AS/MS. SCLEROTIC AV
TRIVIAL AR/TR. NO MR
GOOD LV SYSTOLIC FUNTION, MILD LVH EF 67%
DIASTOLIC DYSFUNTION, NO PAH/PE
ENDOSCOPY DONE ON 21/4/2023 :

Diagnosis
DECOMPENSATED CHRONIC LIVER DISEASE

Treatment Given(Enter only Generic Name)
1. INJ THIAMINE 200 MG IV/BD IN 100 ML NS
2. INJ PAN 40 MG IV/OD
3. INJ VIT K 10 MG IN 100 ML NS
4. SYP LACTULOSE 15 ML PO/BD
5. TAB UDILIV 300 MG PO/BD
Advice at Discharge
TAB UDILIV 300 MG PO/BD X 1 WEEK
TAB.PAN 40 MG PO OD X 1 WEEK
SYP LACTULOSE 15 ML PO/BD
Follow Up
REVIEW TO GENERAL MEDICINE OPD AFTER 1 WEEK OR REVIEW SOS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.

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