A 45 YR OLD MALE WITH ABDOMEN DISTENSION


Case History and Clinical Findings
45 year old male ,lorry driver by occupation,resident of Nalgonda came to the opd with chief
complaints of Abdominal distension since 4-5 days Abdominal bloating since 4-5 days Shortness of
breath since 4-5 days Vomitings since 3 days B/L lower limb swelling since 15-20 daysHOPI:he was
apparently asymptomatic 15 days back then he developed swelling of both lower limbs (extending up
to knee ,pitting type)insidious in onset ,gradually progressive, no aggravating and relieving factors
.Abdominal distension since 5 days ,insidious in onset ,gradually progressive,no aggravating and
relieving factors Associated with bloating ,SOB and vomitingsNo h/o chest pain ,orthopnea
,PND,palpitationsNo h/o deceased urine output,burning micturition ,feverPast historyK/c/o DM since
4-5 years on medication Tab Metformin 500mg po BDN/k/c/o HTN CVA CAD TB EPILEPSYH/o
Alcoholism since 10 years aggrevated 4 yrs back (180ml per day)Personal history:Diet
:mixedAppetite:normalBowel and bladder:regularSleep: adequateAddictions:chronic alocoholic since
10yearsNo known allergiesFamily history:not significantGeneral examination:he is
conscious,coherent , cooperativeWell oriented to time ,place and person
Vitals:
Temp:101.5F
Bp:130/70mmofhg
PR:119bpm
RR:20cpm
Grbs:mg/dl
No clubbing ,cyanosis, lymphadenopathy
CVS:s1s2+,no murmur
RS:BAE+,no added sounds
P/A:
Inspection;
Shape of abdomen; distended
Position of umbilicus: central and inverted
No scars and sinuses are present
All quadrants are moving equally with respiration
Palpation:
No tenderness
No organomegaly
Auscultation:
Bowel sounds heard
CNS: NFND
Investigation
USG ABDOMEN 29/5/23
GRADE 2 FATTY LIVER
HEPATOSPLENOMEGALY
Diagnosis
SEPSIS(UROSEPSIS) WITH MODS
DECOMPENSATED CHRONIC LIVER DISEASE SECONDARY TO ALCOHOL
ACUTE KIDNEY INJURY
ANEMIA UNDER EVALUATION
H/O DM SINCE 5YRS
Treatment Given(Enter only Generic Name)
INJ THIAMINE 200MG IN 100ML NS IV TID
INJ MONOCEF 1 GM IV BD FOR 3 DAYS
INJ MEROPENEM 500MG IV BD
INJ PAN 40MG IV OD
INJ PCM 1GM IV SOS IF TEMP >101F
INJ KCL 1 AMP IN 500ML NS SLOW IV STAT
INJ ZOFER 4MG IV BD
TAB UDILIV 300MG PO BD

SYRUP LACTULOSE 15ML RT TID
SYRUP POTKLOR 15ML RT TID WITH GLASS OF WATER
TAB DOLO 650MG RT SOS
TAB PREGABALIN 75MG RT HS
NEBULISATION WITH IPRAVENT,BUDECORT,MUCOMIST 8TH HRLY
INJ LORAZEPAM 2MG IM SOS
TAB OLANZAPINE 2.5MG RT HS
Advice at Discharge
PATIENT ATTENDORS HAVE BEEN EXPLAINED ABOUT THE DIAGNOSIS AND PROGNOSIS OF
THE CONDITION AND COMPLICATIONS ASSOCIATED WITH THE CONDITION AND NEED FOR
ICU STAY INSPITE OF THAT THEY WANTED TO LEAVE AGAINST MEDICAL ADVISE AS THEY
WANTED TO GO TO OTHER HOSPITAL,AS THEY KNOW A DOCTOR WHO IS WORKING OVER
THERE.
DOCTORS,NURSES AND OTHER HOSPITAL STAFF ARE NOT RESPONSIBLE FOR ANY
MISHAPPENING
Follow Up
PATIENT ATTENDORS HAVE BEEN EXPLAINED ABOUT THE DIAGNOSIS AND PROGNOSIS OF
THE CONDITION AND COMPLICATIONS ASSOCIATED WITH THE CONDITION AND NEED FOR
ICU STAY INSPITE OF THAT THEY WANTED TO LEAVE AGAINST MEDICAL ADVISE AS THEY
WANTED TO GO TO OTHER HOSPITAL,AS THEY KNOW A DOCTOR WHO IS WORKING OVER
THERE.
DOCTORS,NURSES AND OTHER HOSPITAL STAFF ARE NOT RESPONSIBLE FOR ANY
MISHAPPENING
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.

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