A 62 yr old male pt.with abdominal distension


Case History and Clinical Findings
C/O ABDOMINAL DISTENSION
HOPI:PATIENT WAS APPARENTLY ASYMTOMATIC 2 MONTHS BACK THEN DEVELOPED
ABDOMINAL DISTENSION WHICH IS INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE
ASSOCIATED WITH LOW GRADE FEVER , PEDAL EDEMA
NO H/O VOMITINGS , DARK COLORED STOOLS CONSTIPATION +, NO H/O ABDOMINAL PAIN
BURNING MICTURATION . DECRASED URINE OUTPUT
NO H/O OF BREATHLESSNESS , CHEST PAIN , COUGH COLD , PALPITATIONS , PND
,ORTHOPNEA
H/O LOSS OF APPETITE , GENERALISED WEAKNESS +,NO H/O MALENA
NOT A K/C/O DM ,HTN , ASTHMA , CKD ,CVA , THYROID DISORDERS , EPILEPSY
GENERAL EXAMINATION :
PATIENT IS C/C/C
PR 88BPM
BP 110 /80 MMHG
RR 18 CPM
GRBS -107 MG /DL
ABDOMINAL GIRTH 87 CMS
WEIGHT 53 KGS
INPUT/OUTPUT-300/400 ML
SYSTEMIC EXAMINATION
CVS ; S1S2+ ,NO MUMURS
RESPIRATORY ; BAE +, NVBS
CNS : NFND
PER ABDOMEN : DISTENDED , NON TENDER , SHIFTING DULLNESS +, NO ORGANOMEGALY
FLUID THRILL +
PSYCHIATRIC REFERAL WAS DONE :
IMPRESSION :
ALCOHOL DEPENDENCE SYNDROME ( CURRENTLY IN WITHDRAWAL )
TOBACCO DEPENDENCE SYNDROME ( CURRENTLY IN ABSTINENCE)
ADVICED :
TAB OXAZEPAM 15 MG PO/BD (1---X---2)
INJ LORAZEPAM 2 MG 1/2 AMPULE /IM /SOS IF PATIENT IS IRRITABLE AND ANXIOUS
GASTRO REFERAL WAS DONE :
ADVISED UPPER GI ENDOSCOPY :ON 12/3/24
GRADE -III VARICES X 2 COLUMNS
GRADE II VARICES X 1 COLUMN
IMPRESSION - HIGH GRADE ESOPHAGEAL VARICES
VARICEAL LIGATION WAS SUGGESTED
TAB CARDIVAS 3.125 MG /PO/OD
COURSE IN HOSPITAL :
PATIENT WAS ADMITTED IN THE HOSPITAL WITH C/O ABDOMINAL DISTENSION SINCE 2
MONTHS AND WAS INVESTIGATED THAT SHOWED DERRANGED LFT ANDDAIGNOSTIC
TAPPING WAS DONE ON FURTHER EVALUATION WAS DIAGNOSED AS DECOMPESATED
LIVER DISEASE SECONDARY TO ALCHOHOL WITH HIGH GRADE (GRADE III) OESOPHAGEAL
VARICES. GASTROENTEROLOGIST REFERRAL WAS DONE I/V/O ANY VARICEAL BLEED AND
ON UPPER GI ENDOSCOPY SHOWED GRADE -III VARICES X 2 COLUMNS ; GRADE II VARICES
X 1 COLUMN ;IMPRESSION - HIGH GRADE ESOPHAGEAL VARICES AND VARICEAL LIGATION
WAS SUGGESTED.PSYCHIATRY REFERRL WAS DONE I/V/O ALCOHOL DEPENDENCE. THE
PATIENT WAS REFERRED TO HIGHER CENTRE I/V/O ENDOSCOPIC VARICEAL LIGATION.
Investigation
HBsAg-RAPID 11-03-2024 10:12:PM Negative
Anti HCV Antibodies - RAPID 11-03-2024 10:12:PM
BLOOD UREA 11-03-2024 10:12:PM 16 mg/dl 50-17 mg/dl
SERUM CREATININE 11-03-2024 10:12:PM 0.5 mg/dl 1.3-0.8 mg/dlSERUM ELECTROLYTES (Na,
K, C l) 11-03-2024 10:12:PMPOTASSIUM 3.6 mmol/L 5.1-3.5 mmol/LCHLORIDE 98 mmol/L 98-107
mmol/L
SODIUM 133MMOL/L
LIVER FUNCTION TEST (LFT) 11-03-2024 10:12:PMTotal Bilurubin 14.27 mg/dl 1-0 mg/dlDirect
Bilurubin 10.97 mg/dl 0.2-0.0 mg/dlSGOT(AST) 82 IU/L 35-0 IU/LSGPT(ALT) 26 IU/L 45-0
IU/LALKALINE PHOSPHATASE 197 IU/L 119-56 IU/LTOTAL PROTEINS 7.3 gm/dl 8.3-6.4
gm/dlALBUMIN 2.85 gm/dl 4.6-3.2 gm/dlA/G RATIO 0.64
COMPLETE URINE EXAMINATION (CUE) 11-03-2024 10:12:PMCOLOUR BrownishAPPEARANCE
CloudyREACTION AcidicSP.GRAVITY 1.010ALBUMIN ++SUGAR NilBILE SALTS NilBILE
PIGMENTS NilPUS CELLS 2-3EPITHELIAL CELLS fewRED BLOOD CELLS NilCRYSTALS
NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil
USG - CHRONIC LIVER DISEASE WITH HEPATO FUGAL FLOW IN PORTAL VEIN WITH MILD
SPLEENOMEGALY
RAISED ECHOGENICITY OF B/L KIDNEYS
MODERATE TO GROSS ASCITES
UGIE :
GRADE -III VARICES X 2 COLUMNS
GRADE II VARICES X 1 COLUMN
IMPRESSION - HIGH GRADE ESOPHAGEAL VARICES
2D ECHO _
GOOD LV SYSTOLIC FUNCTION
MITAL VALVE - MAC +, AML - DOOMING , PML - FIXED
EF 62 %
IVC 0.7 CMS COLLAPSING , NO RWMA
ASCITIC FLUID ANALYSIS :
SUGARS 130
PROTEIN O.9
AMYLASE 14
ASITIC ALBUMIN -0.43
SERUM ALBUMIN -3.35
SAAG -2.92
LDH -145
HIGH SAAG LOW PROTEINS
HB - 9.1
TC -13700
PLATELETS 1.40 LKHS
APTT 36 SECS
PT 19
INR 1.4
BT 2 SECS
CT 4 SECS
Diagnosis
DECOMPESATED LIVER DISEASE SECONDARY TO ALCHOHOL WITH HIGH GRADE ( GRADE
III) OESOPHAGEAL VARICES.
Treatment Given(Enter only Generic Name)
TAB UDILIV PO/BD 300 MG
TAB RIFAGUT 550 MG PO /B D
TAB LASILACTONE 20/50 PO/.BD
SYP HEPANER 100ML PO/BD
INJ CEFOTAXIM I GM IV .BD
TAB THIAMINE 100 MG PO/BD
Advice at Discharge
PATIENT AND PATIENT ATTENDERS HAVE BEEN EXPALINED ABOUT THE PATIENT
CONDITION - DECOMPENSATED LIVER DISEASE , SECONDARY TO ALCOHOL WITH HIGH
GRADE (III) ESOPHAGEAL VARICES THEIR RISK AND COMPLICATIONS ASSOCIATED WITH IT
I.E VARICEAL BLEEDING SECONDARY TO RUPTURE ,IN THEIR OWN UNDERSTANDABLE
LANGUAGE , THE NEED FOR ENDOSCOPIC VARICEAL LIGATION HAS BEEN EXPLAINED AS
THE PATIENT NEEDS SURGICAL INTERVENTION THE CASE IS BEEN REFERES TO HIGHER
CENTER FOR ENDOSCOPIC VARICEAL LIGATION CASE HAS BEEN DISCUSED AND UPPER GI
ENDOSCOPY WAS PERFORMED BY DR . NAGESHWAR RAO (GASTROENTEROLOGIST)THE
CASE IS BEEN REFERED TO HIGHER CENTRE AFTER DISCUSSING WITH WITH DR.SAVITHA
ASS PROF . HOSPITAL STAFF , DOCTORS AND ADMINISTRATION ARE NOT RESPONSIBLE
FOR ANY UNTOWARDS EVENTS INCLUDING DEATH OUTSIDE THE HOSPITAL
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.

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