38 year old male presented with yellowish discoloration of eyes and abdominal distension
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.
Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.
This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.
Case presentation:
38 year old male ,auto driver by occupation resident of miryalagudem presented with yellowish discoloration of eyes since 15 days
Abdominal distension since 10 days
Patient was apparently asymptomatic 15 days ago
Patient had alcoholic binge for 2 days - 15 days ago , following which he developed yellowish discoloration of eyes , urine since 15 days
Abdominal distension since 15 days gradually progressive
Decreased urine output since 15 days
H/o pedal edema since 2 days
No h/o Malena , hematemesis.
No h/ o SOB
No h/o fever
No h/o burning micturition
No h/o chest pain , palpitations , giddiness
Past h/o :
N/k/c/o DM ,HTN ,CAD ,CVA , EPILEPSY
K/C/O Alcoholic since 10 to 12 years , consumes daily 180 ml
O/E
Patient is c/c/c
Afebrile
No pallor
Icterus present
No cyanosis
No clubbing
No lymphadenopathy
Pedal edema present bilateral ,pitting type presented upto knee
Vitals
PR:120bpm
BP:130/80 mmhg
Spo2:96
RR : 20bpm
P/A:
Inspection :
Shape of abdomen : Distended
Prominent abdominal veins present
ascitic tap was done
No sinuses
Palpation:
No tenderness , no organomegaly .
CVS:s1,s2+
JVP raised
Heaving apex present
Parasternal heave present
RS:
B/LAE + ,NVBS
CNS: NO FND
Investigations
Hemogram
Ascitic fluid albumin- 0.52
Cue
LFT
CHEST X RAY
USG ABDOMEN
ECG
SEROLOGY
- Negative
DIAGNOSIS
Ascites secondary to decompensated liver disease alcoholic liver disease secondary to alcoholism
Rx on the day of admission
1.INJ PANTOP 40 mg IV/OD
2.TAB UDILIV 150MG PO/ BD
3TAB DYTOR 10 MG PO / OD
4 TAB RIFAMIXIN 800 MG PO /OD
5 2 EGG WHITES /DAY
6.TAB LASILACTONE 20/50 MG OD PO
7. SALT AND WATER RESTRICTION ( < 1.5 lit/day)
Day 1
Pt is c/c/c
BP - 120/80 mmhg
PR-86bpm ,regular
CVS- S1,S2 + , NO murmurs
RS - BAE + , CLEAR
P/A -
DISTENDED
Abdominal girth - 80cms
I/o - 400/600 ml
Grbs - 113 mg/dl
DIAGNOSIS
Ascites secondary to decompensated liver disease alcoholic liver disease secondary to alcoholism
Rx
1.INJ PANTOP 40 mg IV/OD
2.TAB UDILIV 150MG PO/ BD
3TAB DYTOR PLUS 10 MG PO / OD
4 TAB RIFAMIXIN 800 MG PO /OD
5 INJ ZOFER 4MG /IV /SOS
6.2 EGG WHITES /DAY
7..TAB LASILACTONE 20/50 MG OD PO
8.ALT AND WATER RESTRICTION ( < 1.5 lit/day)
9. Daily weight monitoring and abdominal girth measurement
10. STRICT I/O charting
Day 2
Pt is c/c/c
No fever spikes
BP - 120/80 mmhg
PR-102 bpm ,regular
CVS- S1,S2 + , NO murmurs
RS - BAE + , CLEAR
P/A -
DISTENDED
No organomegaly
Abdominal girth - 80cms
Weight - 46.1kgs
I/o - 600/700 ml
Grbs - 124 mg/dl
DIAGNOSIS
Decompensated liver disease secondary to alcoholism
K/c/o alcoholic since 12 yrs
Rx
1.INJ PANTOP 40 mg IV/OD
2.TAB UDILIV 150MG PO/ BD
3TAB DYTOR PLUS 10 MG PO / OD
4 TAB RIFAMIXIN 800 MG PO /OD
5 INJ ZOFER 4MG /IV /SOS
6.2 EGG WHITES /DAY
7.LT AND WATER RESTRICTION ( < 1.5 lit/day)
8. Daily weight monitoring and abdominal girth measurement
9. STRICT I/O charting
10. NBM Since 12 Am
Comments
Post a Comment