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A 48 year old male farmer by occupation came to causality with chief complaints of stomach pain since 10 days , intermittent fever from 10 days , he also had 1 episode of vomiting 10 days back
History of present illness:
Daily routine:
He used to get up early in the morning by 6:00 am and drink tea . By 9:00 am he used to have his breakfast. He was not having lunch from 5 to 6 months due to indigestion . By 6:00 to 7:00 pm he takes his dinner .
He was not going for work since 5 years .
Patient was apparently asymptomatic before 10 years back later seeing his son in depression in 10th grade he went to depression and got addicted to alcohol. 9 years back he went to severe depression and commited suicide by swallowing poison and admitted in KIMS Nkp.
3 months back he developed bilateral pedal edema and abdominal distension due to which ascitic tap was done and discharged .
10 days after discharge he again developed ascites and pedal edema . Ascitic tap was done in hyderabad .
Past history :
5 years back he had developed pain in abdomen , diagnosed with cholelithiasis for which he underwent laparoscopic cholecystectomy.
2 years back there was yellowish discoloration of sclera and urine ,diagnosed with chronic liver disease
Diabetes mellitus since 8 years
No hypertension , asthma , epilepsy , tuberculosis .
Personal history:
Diet : mixed
Bowel and bladder movement: regular
Apetite: normal
Sleep : adequate
Urine output :normal
Consumes alcohol regularly 250ml
General examination:
Temp-98.2 degrees F
PR-90bpm
RR-20 cpm
BP-130/90 mm Hg
Spo2:97% @ room air
GRBS:95 mg%
CVS:S1S2+
RS:BAE+
P/A: distended,non tender
CNS:NFD
Investigations:
Rapid test for covid : negative
BT - 2:30
CT - 5:00
Hb - 8.4 gm/dl
TC - 7000
PCV - 23.8
PL.C - 1.10
PT - 24
APTT - 24 sec
INR 1.77
S.Urea - 32
S.creat 0.7
Na - 142
K - 3.1
Cl - 98
Ascitic sugar - 90
Ascitic protein - 1.2
Ascitic LDH - 150
S. Albumin - 2.4
Ascitic albumin - 0.5
SAAG - 1.9
Ascitic fluid amylase - 39
RBS - 79
TREATMENT :
1)T.LASIX 40 MG PO/BD
2)T.ALDACTONE 50 MG PO/OD
3)PROTEIN X POWDER 2 SCOOPS IN 100ML MILK
4)INJ.THIAMINE 1 AMP IN 100ML NS IV/OF
5)INJ.OPTINEURON 1 AMP IN 100 ML NS IV/OD
6) DAILY BODY WEIGHT AND ABDOMINAL GIRTH MONITORING
7) STRICT I/O CHARTING
8) FLUID RESTRICTION <1.5 LITRES PER DAY
9)SALT RESTRICTION <2 GM/DAY
10) GRBS CHARTING 8TH HOURLY
Ascitic fluid tap :
Under strict aseptic precautions with procedure and related complications explained to patient and attenders the procedure was performed.site was confirmed and cleaned.10 c.c syringe needle was placed.600 ml of ascitic fluid was extracted.Post procedure patient vitals are stable.
BP 110/80 mmhg
PR 85bpm
Spo2 98%
22/11 /21
No fever spikes ,complained of scrotal edema , generalised pruritis and inguino scrotal swelling with abdominal distension .
BP : 100/70mmhg
PR : 88Bpm
CVS : S1 S2 heard
RS : 22CPM
Abdominal girth : 108cm
Weight : 82kg
Chronic liver disease with gross ascitis inguino scrotal swelling with scrotal edema.
TREATMENT:
1)T.LASIX 40 MG PO/BD
2)T.ALDACTONE 50 MG PO/OD
3)PROTEIN X POWDER 2 SCOOPS IN 100ML MILK
4)INJ.THIAMINE 1 AMP IN 100ML NS IV/OF
5)INJ.OPTINEURON 1 AMP IN 100 ML NS IV/OD
6) DAILY BODY WEIGHT AND ABDOMINAL GIRTH MONITORING
7) STRICT I/O CHARTING
8) FLUID RESTRICTION <1.5 LITRES PER DAY
9)SALT RESTRICTION <2 GM/DAY
10) GRBS CHARTING 8TH HOURLY
23/11/21
No fever spikes ,C/O abdominal distension with inguino scrotal swelling with scrotal edema , generalised pruritis .
BP : 110/70mmhg
PR : 80bpm
Cvs : S1 S2 heard
RS : 22 CPM
Abdominal girth :118cm
Weight : 80kg
Treatment:
1)T.LASIX 40 MG PO/BD
2)T.ALDACTONE 50 MG PO/OD
3)PROTEIN X POWDER 2 SCOOPS IN 100ML MILK
4)INJ.THIAMINE 1 AMP IN 100ML NS IV/OF
5)INJ.OPTINEURON 1 AMP IN 100 ML NS IV/OD
6) DAILY BODY WEIGHT AND ABDOMINAL GIRTH MONITORING
7) STRICT I/O CHARTING
8) FLUID RESTRICTION <1.5 LITRES PER DAY
9)SALT RESTRICTION <2 GM/DAY
10) GRBS CHARTING 8TH HOURLY
24 /11/21
Bp: 110/70 mmhg
PR : 80bpm
CVS : S1 S2 heard
RS : 22 Cpm
Abdominal girth: 117cm
Weight: 79kg
25/11/21
Total bilirubin : 5.11 mg/dl
Direct bilirubin : 1.16 mg/dl
SGOT : 54 IU/L
ALT : 19 IU/L
Alkaline Phosphate 190 /L
Total proteins - 6.2 gm/dl
Albumin 2.12 gm/dl
Sr.Na : 131 mEq/L
Sr K : 3.9 mEq/L
Sr Cl : 92 mEq/L
APTT : 40 sec
Prothrombin time 21 sec
INR : 1.5 sec
26 /11/ 21
Bp : 110/ 70 mmhg
PR : 80bpm
CVS : S1 S2 heard
RS : 22cpm
Abdominal girth : 118cm
Weight : 80kg
TREATMENT:
1)T.LASIX 80 MG PO/BD
2)T.ALDACTONE 50 MG PO/OD
3)PROTEIN X POWDER 2 SCOOPS IN 100ML MILK
4)INJ.THIAMINE 1 AMP IN 100ML NS IV/OF
5)INJ.OPTINEURON 1 AMP IN 100 ML NS IV/OD
6) DAILY BODY WEIGHT AND ABDOMINAL GIRTH MONITORING
7)TAB.CETRIZINE PO BD
8) SYP LACTULOSE 10ML PO BD
STRICT I/O CHARTING
9) FLUID RESTRICTION <1 LITRES PER DAY
10)SALT RESTRICTION <2 GM/DAY
11) GRBS CHARTING 8TH HOURLY
27/11/21
Bp : 120/80mmhg
PR : 78bpm
CVS : S1 S2 Heard
RS : 21Cpm
Abdominal girth: 118cm
Weight : 83kg
TREATMENT:
1)T.LASIX 80 MG PO/BD
2)T.ALDACTONE 50 MG PO/OD
3)PROTEIN X POWDER 2 SCOOPS IN 100ML MILK
4)INJ.THIAMINE 1 AMP IN 100ML NS IV/OF
5)INJ.OPTINEURON 1 AMP IN 100 ML NS IV/OD
6) DAILY BODY WEIGHT AND ABDOMINAL GIRTH MONITORING
7)TAB.CETRIZINE PO BD
8) SYP LACTULOSE 10ML PO BD
STRICT I/O CHARTING
9) FLUID RESTRICTION <1 LITRES PER DAY
10)SALT RESTRICTION <2 GM/DAY
11) GRBS CHARTING 8TH HOURLY
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