54 YEAR OLD MALE PATIENT WITH DISTENTION OF ABDOMEN, JAUNDICE, BURNING MICTURITION SINCE 15 DAYS
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A 54 YEAR OLD MALE PATIENT CAME WITH COMPLAINTS OF
1. DISTENSION OF ABDOMEN SINCE 15 DAYS
2. H/O YELLOWISH discoloration of eyes SINCE 15 DAYS
NO H/O FEVER,SOB,PEDAL EDEMA
HOPI:
PATIENT WAS APPARENTLY ASYMPTOMATIC 4 MONTHS BACK, ON JAN 2021 PATIENT WAS OPERATED FOR GALL STONES AND WAS TOLD THERE IS SOME PROBLEM IN THE LIVER.
POST OP NO COMPLICATIONS AND WAS NORMAL . PATIENT DEVELOPED JAUNDICE ( YELLOWISH DISCOLOURATION OF SCLERA AND SKIN ) 15 DAYS BACK AND WAS TAKEN TO HOSPITAL AND GOT EVALUATED AND TREATED AS CHRONIC LIVER DISEASE SECONDARY TO ALCOHOL ,?HEPATORENAL SYNDROME.NOW CAME TO OUR HOSPITAL WITH TIGHTNESS OF ABDOMEN AND NEED FOR PARACENTESIS
H/O CHRONIC ALOCHOLISM ( SINCE 20YEARS 180ML / DAY ) STOPPED 4MONTHS BACK
H/O SMOKING FOR 5 YEARS ( 5 CIGERS/DAY) STOPPED 10MONTHS BACK
NOT A K/C/O HTN, DM, ASTHMA, EPILEPSY
VITALS:
TEMP: 98.4 F
PR: 78/MIN
RR: 23/MIN
BP: 110/70 MMHG
NO PALLOR/CYANOSIS/ICTERUS/CLUBBING/OEDEMA
INVESTIGATIONS:
Ascitic tap :
25/04/2022 2.5lit done outside
27/04/2022 : 1.5 lit done outside
3/5/2022 : 1.5lit done here
PRE TAP BP -100/60Mmhg
POST TAP BP-100/60mmhg
Treatment advice
Tab udiliv 300mg BD
Tab Aldactone 25mg OD
Tab Lasix 20mg BD
Syp Lactulose 10ml H/S
DIAGNOSIS:
DECOMPENSATED CHRONIC LIVER DISEASE WITH GROSS ASCITES AND OESOPHAGEAL VARICES
TREATMENT GIVEN:
1) UNDER ASEPTIC CONDITIONS , ASCITIC TAP DONE AND 1.5 L WAS DRAINED
2) TAB.UDILIV 300MG/PO/BD
2)TAB.ALDACTONE 25MG/PO/OD
3)TAB.LASIX 20MG/PO/BD
4)SYP.LACTULOSE 10ML/PO/BD
