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a 53-year-old male, a Hotel owner and chief by occupation,
The patient presented to the hospital with chief complaints of
- Swelling of both Legs since 10 days
- Swelling of face since 7 days
HISTORY OF PRESENTING ILLNESS
The patient was apparently asymptomatic 10 days ago.In the first week of June he had a binge of alcohol on occasion of local festival. Later he observed abdominal distension, followed by Bilateral Pedal odema which is pitting type extending up to the knee, insidious in gradually progressive , since one week .
Patient has decreased urine output since 5 days not associated with burning micturation
- yellowish discolouration of urine
No c/o - Chest pain, Palpitations , Shortness of breath ,Orthopnea, PND
No c/o - Fever , Vomitings , loose stools.
PAST HISTORY
Not K/N/C- Hypertension, Epilepsy, Thyroid disorders.
PERSONAL HISTORY
Mixed diet, decreased appetite,constipation decreased urinary frequency.
K/C/O - Chronic Alcoholic since 20 yrs , every day consumption around 360 ml
Last consumption 1 week back.
GENERAL EXAMINATION
Patient was conscious ,non-coherent , cooperative ,well built and nourished not so well oriented to time place & person at the time of presentation.
Pallor- present
Icterus-present
Cyanosis-absent
Clubbing-present
Lymphadenopathy-absent
Edema -present b/l pitting type .
VITALS
Temperature-97.6'f
Pulse rate -90bpm.
Bp-150/80mm hg
RR-17cpm
Spo2-99% .
grbs-110mg/
Abdomen examination
INSPECTION:-
Shape of abdomen -distended
Umbilicus-inverted.
No scars ,sinuses,straie
No visible pulsations & visible peristalsis.
Moments of all 4quadrants moving equally with respiration
Abdominal Distension
Ecchymosis on Left shoulder
Icterus present
Bilateral Pitting Oedema
Percussion:-
Shifting dullness-+
No signs of fluid thrill.
CVS:-
S1,S2heard ,no murmurs.
CNS :-
Higher motor functions - intact
Cranial nerves - intact
Sensory system - intact
Cerebellar functions are normal
Respiratory examination:-
Trachea is central
Chest moments -normal
Bae-+
09.06.2023 - 10.06.2023
11.06.2023
U.S.G impressions
ECG
Chest X-ray
12.06.2023
13.06.2023
Ascitic Fluid
Volume-3ml
Colour-clear
Rbc-nil
Tc-50
Dc-100
Others nil
ENDOSCOPY FINDINGS:
Esophagus : Grade -1 Esophageal varices (2 columns)
Stomach : Severe PHG ( portal hypertension gastropathy)
Duodenum: D1 D2 normal
Impression : Severe PHG with Grade -1 Esophageal varices
PROVISIONAL DIAGNOSIS:
DECOMPENSATED CHRONIC LIVER DISEASE WITH PORTAL HYPERTENSION (SPLENOMEGALY,MODERATE ASCITIS) WITH THROMBOCYTOPENIA SECONDARY TO CLD ? B12 DEFICIENCY WITH ALCOHOL WITHDRAWAL STATE.
Treatment
Fluid restriction <2l /day
Injection - vitk IV/ OD ( 1Amp in 100 ml NS)
CAP-evion 400mg PO/OD
Tab- Benfothiamine 100mg PO/ TID
Tab UDILIV 300mg PO/BD
Tab Lorazepam 2mg 1-1-2
Tab Baclofen 20mg OD(HS)
Tab Aldactone 50mg OD 2pm
Syrup-lactulose 15ml / PO/ BD
Salt restriction <2l/day
Protein rich diet (2egg white/day)
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