A 51 yr old male pt.with CLD
Case History and Clinical Findings
HOPI :PATIENT WAS APPARENTLY ASYMPTOMATIC 6 MONTHS BACK THEN HE DEVELOPED
?JAUNDICE AND GOT TREATED WITH PRACTIOTNER AND SUBSIDED THEN HE DEVELOPED
DISTENSION OF ABDOMEN WHICH WAS SLOWLY PROGRESSING TO THE PRESENT SIZE
A/W PAIN AT EPIGASTRIUM AND RIGHT HYPOCHONDRIUM NOT ASSOCIATED WITH
NAUSEA,VOMITING. NO H/O FEVER,LOOSE STOOLS A/W SHORTNESS OF BREATH SINCE
5DAYS.PATIENT IS KNOWN ALCOHOLIC SINCE 20YEARS STOPPED 6MONTHS BACK BUT
HAD HIS LAST DRINK SUNDAY 29/5/22 (BEER AND TODDY) AFTER WHICH ASCITES HAS
INCREASED
PAST HISTORY : N/K/C/O DM,HTN,ASTHMA,CAD AND EPILEPSY.
Investigation
USG IMPRESSIONS
COARSE ECHOTEXTURE AND IRREGULAR SURFACE OF LIVER - CHRONIC LIVER DISEASE
GROSS ASCITES
GALL BLADDER SLUDGE
2D ECHO
NO RWMA
GOOD LV SYSTOLIC FUNCTION
DIASTOLIC DYSFUNCTIONS
Diagnosis
ACUTE DECOMPENSATED LIVER DISEASE/ALCOHOLIC LIVER WITH GROSS ASCITES
Treatment Given(Enter only Generic Name)
1)INJ LASIX 40MG IV BD
2)INJ PAN 40MG IV OD
3)INJ THIAMINE 1AMP 100ML NS IV TID
4)TAB SPIRONOLACTONE 50MG PO BD
5)SYP.LACTULOSE 15ML PO H/S
6)SYP POTCHLOR 10ML PO TID
Advice at Discharge
1)TAB.LASIX 40MG BD
2)TAB.SPIRINOLACTONE 50MG PO BD
3)TAB.MVT PO OD
$)SYP.LACTULOSE 15ML PO H/S
6)SYP.POTCHLOR 10ML PO TID
Follow Up
REVIEW AFTER 15 DAYS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.
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