A 35 yr old male pt.with abdomen pain

Case History and Clinical Findings

C/O PAIN ABDOMEN SINCE 10 DAYS WITH LOSS OF APETTITE,DISTENSION OF ABDOMEN

SINCE 6 DAYS ,PEDAL EDEMA SINCE 5 DAYS ,YELLOWISH DISCOLORATION OF URINE

SINCE 8 DAYS.

PATIENT WAS APPARENTLY ASYMPTOMATIC 10 DAYS BACK THEN HE DEVELOPED PAIN

ABDOMEN WHICH IS DRAGGING TYPE,DIFFUSE PAIN ALL OVER THE ABDOMEN.PEDAL

EDEMA SINCE 5 DAYS WHICH IS PITTING TYPE BELOW KNEES OF BOTH LIMBS.H/O LOSS OF

APETITE,DECREASED URINARY OUTPUT

N/K/C/O HYPERTENSION, ASTHMA,EPILEPSY,CAD,CVA.

K/C/O DM SINCE 6 MONTHS ON METFORMIN,CHRONIC ALCHOLIC SINCE 15 YEARS.

GENERAL EXAMINATION ,

VITALS;

BP;110/70 MM/HG

PR;64 BPM

RR;16 CPM

SPO2; 98%

GRBS;67 MG%

SYSTEMIC EXAMINATION ; CARDIOVASCULAR EXAMINATION ; S1S2 HEARD,NO

THRILLS,MURMERS

RESPIRATORY SYSTEM; NO DYSPNOEA,WHEEZE,VESICULAR BREATH SOUNDS HEARD

P/A; SOFT ,NON TENDER,ABDOMEN DISTENDED,ENGORGED VEINS + ,SHIFTING DULLNESS

+

CENTRAL NERVOUS SYSTEM; NO ABNORMALITIES DETECTED

PATIENT WAS ADMITTED WITH THE ABOVE MENTIONE COMPLAINTS AND NECESSARY

INVESTIGATIONS WERE SEND AFTER INITIAL ASSESSMENT .UPON ADMISSION HIS GRBS 78

.HE WAS DROWSY AND CONFUSED AT THE TIME OF ADMISSION .PSYCHIATRY OPINION

WAS TAKEN I/V/O IRRITABILITY ,AGITATED AND IN ALTERED SENSORIUM THEY

SUGGESTED OD PSYCHO EDUCATED ,TAB. LORAZEPAM 2 MG, INJ.LORAZEPAM 1/3 AMP

IM/SOS IF IRRITABLE OR AGITATED ,TAB.OLANZAPINE 2.5 MG ,ORIENTATION MONITORING 4

TH HOULY.GASTROENTROLOGIST OPINION WAS TAKEN I/V/O GRADE 2 HEPATIC

ENCEPHALOPATHY WITH CLD SECONDARY TO ALCOHOL DIRECT HYPER BILIRUBENEMIA

AS THEY ADVISED SYP.DUPHALAC 15 ML/PO/6 TH HOURLY TILL HE PASSES THE STOOL 3-4

TIMES/DAY.ENT OPINION WAS TAKEN I/V/O EAR PAIN AND EAR DISCHARGE FROM LEFT

EAR AS THEY ADVISED -CANDIBIOTIC EAR DROPS,KEEP EAR DRY,AVOID MANIPULATION

OF EAR.

Investigation

USG-ENLARGED LIVER WITH ATTEND ECHOTEXTURE S/O CLD ,CORRELATE WITH LFT,GB

WALL EDEMA WITH SLUDGE,GROSS ASCITIES

REVIEW USG-ENLARGED LIVER WITH ALTERED ECHOGENECITY WITH GROSS ASCITIES S/O

CLD

2D ECHO; NO RWMA,MODERATE TR AND MILD PAH ,MILD AR; MILD MR,NO AS/MS.EF=62%

,GOOD LV SYSTOLIC FUNCTION,NO DIASTOLIC DYSFUNCTION,NO PE.IVC SIZE (1.82 CMS)

DILATED NON COLLAPSING .MILD DILATED (R.A SIZE=3.95 CMS,L.A SIZE=3.8 CMS,R.V SIZE

=3.75 CMS)

CYTOLOGY REPORT;

CYTOSMEAR STUDIED SHOWS PREDOMINANTLY LYMPHOCYTES,FEW NEUTROPHILS AND

OCCASIONAL MESOTHELIAL CELLS AGAINST PROTEINACEOUS BACKGROUND .NO

EVIDENCE OF ATYPICAL CELLS.

HEMOGRAM;

 16/12 17/12 18/12 19/12 20/12 21/12 22/12 23/12 24/12 25/12 26/12

HB; 11.3 9.9 10.3 10.6 10.8 10.3 9.7 9.4 9 9.4 9.1

TLC;12,000 14000 13800 13900 15440 17450 14610 14500 17100 17400 17000

NEUTRO;60 65

LYMPH; 24 28

EOSINO; 1 00

MONOCYTE;15 7

BASOPHIL ;00 00

PCV;34.5 29.9

MCV;100.6 99

MCH;32.9 32.2

MCHC;32.8 33.2

RDW-CV;13.2 14

RDW-SD;49.9 49.2

RBC COUNT;3.43 3.02

PLC;1.74 1.6 1.1 1.1 1.1 1.02 1.01 95000 1.3 1.50 1.7 2.11

ASCITIC FLUID PROTEIN SUGAR ;

SUGAR 85 MG/DL

PROTEIN; 0.9 G/DL

ASCITIC FLUID AMYLASE;14.7

ASCITIC FLUID LDH; 65.3 IU/L

CELL COUNT OF ASCITIC OR PERITONEAL FLUID ;

OCCASIONAL MESOTHELIAL CELL.

VOLUME = 2 ML

APPEARS; CLEAR

COLOR; PALE YELLOW

TLC; 50 CELLS/CUM

NEUT; 10%

LYMP; 90 %

SEROLOGY-NEGATIVE

B/G; O +

BACTERIAL CULTURE AND SENSITIVITY REPORT;

NO GROWTH AFTER 24 HOURS OF AEROBIC INCUBATION

ASCITIC FLUID C/S; GRAM STAIN-OCCASSIONAL INFLAMMATORY CELLS,NO ORGANISMS

SEEN.

ZN STAIN- NO ACID FAST BACILLI SEEN .SKIN COMMENSALS GROWN.(DIPHTHERIODS)

BLOOD C/S; NO GROWTH AFTER 3 DAYS AND 7 DAYS OF AEROBIC INCUBATION

Diagnosis

DECOMPENSATED LIVER DISEASE WITH PORTAL HYPERTENSION (HIGH SAAG LOW

PROTEIN)

DIRECT HYPER BILIRUBENEMIA

CHRONIC PANCREATITIS,SUBCLINICAL HYPOTHYROIDISM

HEPATIC ENCEPHALOPATHY- GRADE I(RESOLVED),BED SORE - GRADE I(RESOLVED)

K/C/O DM2 SINCE 6 YEARS

Treatment Given(Enter only Generic Name)

1.IVF 1 PINT NS @ 50 ML/HR

2.INJ.LASIX 40 MG IV/BD

3.TAB.ALDACTONE 50 MG PO/OD

4.TAB.UDILIV 300 MG RT/BD

5.SYP.LACTULOSE 15 ML PO/TID

6.ENEMA STAT

7.INJ.MONOCEF GM IV/BD*5 DAYS

8.CANDIBIOTIC EAR DROPS*1 WEEK

9.FREQUENT CHANGE IN POSITION 4 TH HOURLY

10.SALT RESTRICTION (<2 GRM/DAILY)

11.FLUID RESTRICTION (<1.5 LIT/DAILY)

12.INJ.KCL 2 AMP IN 500 ML NS OVER 4 HRS IV/STAT

13.GRBS MONITORING 2 ND HOURLY-GRBS 7 PINT PROFILE

14.VITALS MONITORING 4 TH HOURLY

15.SYP.HEPARMERZ 10 ML RT/TID

16.INJ.THIAMINE 200 MG IV/BD

17.3-4 EGG WHITES/DAY

18.PROTIEN -X POWDER 3-4 SCOOPS IN 1 GLASS OF MILK RT/TID

19.INJ.VIT.K 10 MG IV/OD OVER 10 MIN *3 DAYS

20.TAB.RIFAGUT 550 MG PO/BD

21.SYP.POTKLOR 15 ML IN GLASS OF WATER TID

22.PLAN FOR FFP TRANSFUSION ON 16/12/22

23.TAB.LORAZEPAM 2 MG PO/SOS

24.TAB.OLANZAPINE 2.5 MG PO/OD-SOS

25.SYP.DUPHALAC 15ML PO/6TH HRLY

Advice at Discharge

1.TAB.ALDACTONE 50 MG PO/OD

2.TAB.UDILIV 300 MG PO/

3.SYP.LACTULOSE 15 ML OD/HS

4.SYP.HEPARMERZ 10 ML PO/TID

5.TAB.THIAMINE 100 MG PO/BD

6.3-4 EGG WHITES/DAY

7.PROTIEN -X POWDER 3-4 SCOOPS IN 1 GLASS OF MILK PO/TID

8.TAB.VIBOLIV 500 MG PO/BD

9.SYP.POTKLOR15 ML IN 1 GLASS OF WATER PO/TID*4 DAYS

Follow Up

REVIEW TO GEN MEDICINE OPD AFTER 1 WEEK

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.