CHIEF COMPLAINT :
C/o yellowish discolration of eye since 1 month
C/o SOB since 1 week
C/o b/l leg swelling since 1 week
HOPI
Patient was apparently alright 1 month ago after which he developed yellowish discoloration of eyes since 1 month insidious in onset ,gradually progressive . C/o SOB since 1 week insidious in onset , gradually in progressive from grade 1 to grade 111 (mmrc) .Aggrevated on walking , talking and relieved on taking rest .No c/o orthopnea ,PND , c/o B/L pedal edema pitting type , insidious in onset gradually progressed from ankle to below knee . C/O pain abdomen , drgging type of pain in right hypogastric region , non radiating , not associated with nausea ,vomiting and loose stools .c/o passing black colored stools (malena + ), loss of appetite + loss of weight +
H/O similar episodes 1 month back
H/O hematemesis 5 months ago
PAST HISTORY
K/C/O DM since 1 year and on Tab GLIMI -M2 po/
N/k/C/o HTN , CAD ,CVA ,TB ,Asthma , Epilepsy
PERSONAL HISTORY
diet - mixed
Appetite - lost
Bowel and bladder - regular
No knoen allergies
Regular alcohol consumption since 6 yrs ( 2-4 quaters /day )
H/o consumption of betel leaf since 5 years
No H/O consumption of tobacco
FAMILY HISTORY
not significant
TREATMENT HISTORY
TAB GLIMI M2 since 1 yr
GENERAL EXAMINATION
PT is conscious coherent and cooperative
Pallor and Icterus , b/lpedal edema present
No cyanosis , clubbing , generalized lymadenopathy
B/L Parotiditis +
Alopecia +
Gynaecomastia -ve
Spider naevi -ve
Duptyren contracture -ve
Palmar erythema -ve
Caput medusae -ve
No genital atrophy
SYSTEMIC EXAMINATION:
CARDIOVASCULAR SYSTEM:
S1,S2 heard,Apex at 4th ICS lateral to midclavicular line
No thrills, No murmurs
RESPIRATORY SYSTEM:
Normal vesicular breath sounds heard
Trachea centrally placed
Decreased breath sounds in left infra mammary and mammary region
PER ABDOMEN EXAMINATION:
Tenderness in Right hypochondrium region
Shifting dullness
No palpable mass, no bruits, no hernial orifices
Liver and spleen not palpable
CENTRAL NERVOUS SYSTEM:
Patient is conscious coherent and cooperative
Normal speech
GCS -E4V5M6
No Neurological focal deficits
No signs of Meningeal irritation
PROVISIONAL DIAGNOSIS:
DeCompensated Chronic Liver disease ,with SBP WITH HIGH SAAG ,LOW PROTEINS ,GRADE 1 HEPATIC ENCEPHALOPATHY
PORTAL HYPERTENSION
K/C/O TYPE 3C DM since 1 month (2° to chronic pancreatitis)
SEVERE ANAEMIA ( Anemia of chronic disease)
LEFT SIDED PLEURAL EFFUSION ( ? HEPATIC HYDROTHORAX
INVESTIGATIONS:
Hb - 5.5g/dl
TLC - 22000cells /cumm
Platelet count - 1 lakh
Urea - 11mg/dl
S creat - 0.8mg/dl
Na - 134mmol/l
K- 3.2mmol/l
Cl - 101mmol/l
Ca - 1.13mmol/l
TB - 1.78mg/dl
DB - 0.48mg/dl
SGOT - 31IU/L
SGPT - 18IU/L
ALP - 204 IU/L
TP 5.4
Albumin - 1.9g/dl
A/G - 0.564
PT - 18sec
APTT - 37sec
INR - 1.3
LDH - 111IU/L
S.Amylase 25IU/L
S.iron - 88ug/l
Lipase - 13 IU/L
Serology - -ve
CUE:
Color - pale
Appearance - clear
Reaction - acidic
Sp gravity - 1.010
Albumin - nil
Sugar - nil
Bile salts - nil
Bile pigments - nil
Pus cells - 2-3
Crystals - nil
Red blood cells - nil
Amorphous deposits - aabsent
S.creatinine - 0.8mg/dl
Ascitic fluid :
Sugar - 96mg/dl
Protein - 1.2g/dl
Amylase - 10.5IU/L
LDH - 136.9IU/L
S. Alb - 1.9g/dl
Ascitic albumin - 0.55g/dl
SAAG - 0.35
TREATMENT
5/5/24
1) FLUID RESTRICTION - <1.5 lit /day
2) SALT RESTRICTION & 1. 5 Lit day
3) INJ PAN - 40ng IV STAT
4) INJ PAN 2Amp (80mg) in 50ml NS @5ml / hr
5) INJ TRANEXA 1gm IVSTAT
6) INT OCTREOTIDE 100ug SC/Tid
7) INJ VIT-K 10mg In 4ml NS IN| STAT
8) T. LASILACTONE 20/50PO BD
9) T UDILIV 300mg PO/BD
10) T RIFAGUT 550 mg PO / BD
11) syp LACTULOSE 10ml PO /HS
12) strict I/O charting
13) Weight and abdominal girth monitoring
14) MONITOR VITALS
17) 4 egg whites /day
18) Inj KCL 40 meq in 300 ml NS
6/5/24
1) NBM Till Further orders
2) FLUID RESTRICTION <1.5 lit/day
3), SALT RESTRICTION: < 1.5 g/day
4) INT TAXIM 1gm IV/BD
5) INJ PAN 2Amp (80mg) in 50ml NS @5ml/hr
6) INJ OCTREOTIDE 100Ug SC/TID
7) INJ VIT-K 100g in 4ml NS IN/ OD
8) INJ OPTINEURON lamp in 100ml NS
9) INJ THIAMINE 200mg /iv/ BD
10) INJ ZOFER - 4mg iv/ TID
11) INJ NEOMOL 1gm /iv/sos
12) T. LASILACTONE 20/50PO BD
13) T UDILIV 300mg PO/BD
14) T RIFAGUT 550 mg PO / BD
15)syp LACTULOSE 20ml PO/TID
16)strict I/O charting
17)Weight and abdominal girth monitoring
18)MONITOR VITALS
19)4 egg whites /day
20) NESTLE HEPATIC PROTEIN POWDER
3 scoops in 1 glass milk
21) syp POTKLOR 15 ml/PO/TID
7/5/24
1)FLUID RESTRICTION <1.5 lit/day
2) SALT RESTRICTION: < 1.5 g/day
3)INT TAXIM 2gm IV/BD
4)) INJ PAN 2Amp (80mg) in 50ml NS @5ml/hr
5) INJ OCTREOTIDE 100Ug SC/TID
6) INJ VIT-K 100g in 4ml NS IN/ OD
7) INJ OPTINEURON lamp in 100ml NS
8) INJ THIAMINE 200mg /iv/ BD
9) INJ ZOFER - 4mg iv/ TID
10) INJ NEOMOL 1gm /iv/sos
11) T. LASILACTONE 20/50PO BD
12) T UDILIV 300mg PO/BD
13) T RIFAGUT 550 mg PO / BD
14)syp LACTULOSE 20ml PO/TID
15)strict I/O charting
16)Weight and abdominal girth monitoring
17)MONITOR VITALS
18)4 egg whites /day
19) NESTLE HEPATIC PROTEIN POWDER
3 scoops in 1 glass milk
20) syp POTKLOR 15 ml/PO/TID
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