30year male with ascites,CLD

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This E-LOG was done under the guidance of Dr. Madhumitha 

CHIEF COMPLAINT: 

CHIEF COMPLAINT:  

A 31 year old male, a photographer by occupation  came to the opd with chief complaints of 

• Abdominal pain and distension since 3 days 

• Pedal edema extending upto knees since 3 days 

• Fever  ,low grade since 4 days

HISTORY OF PRESENT ILLNESS: 

Patient was apparently asymptomatic 1 year back then he had pain in abdomen,in the right upper quadrant, nit associated with vomitings. 

Patient complains of Loss of appetite, anorexia,  . weight loss ,malaise , fatigue and generalised weakness  since one year . 

He stopped drinking due to the pain and got treated from local RMP for the pain. 

After the pain has subsided, ,he started to drinking  again. He had multiple attacks of pain in the abdomen , in the right upper quadrant  and progressive distemsion of abdomen  during the past 1yr. And history of multiple episodes  hematemisis ,Melena

Since one year .

Two months back he had c/o yellowish discoloration of eyes, pain in the abdomen,in the right upper quadrant  and  b/l pedal edema from foot to knee, Melina.   for which he got treated at NIMS, his symptoms subsided within 2 days. 

Then he was tested positive for COVID-19 by RTPCR test, for which he referred to Gandhi hospital and took medication for 10 days and went back home. By that time yellowish discoloration of eyes was still present. 

 15 days  back he had non-vegetarian food(mutton) for his dinner, and then developed pain in the abdomen in the right upper quadrant associated with abdominal distension , pedal edema and fever  for which he got treated in our hospital for a week , upper gi endoscopy was done grade 1 esophageal varies wer seen . Ascitic tap was done and ascitic tap revealed high saag low protein was seen . discharged after the symptoms subsided .

There was insidious onset of Abdominal distension, pedal edema extending upto knees and Fever(Intermitent, low grade, relieved with medication) since 4 days.

HISTORY OF PAST ILLNESS: 

Not k/c/o DM, hypertension, asthma, epilepsy, Heart disease or tuberculosis. 

He has a treatment history which has been taken for RTA which occurred twice once in 2007 and 2014, where he got treated for head injury in both the cases in 2 different hospitals. 

No treatment history for DM, hypertension, asthma, epilepsy, Heart disease or tuberculosis. 

FAMILY HISTORY : 

No family history of liver disease , hypertension,  diabetis . 

PERSONAL HISTORY: 

He has been consuming alcohol 180ml/day and smoking 1 pack of cigarette/day since past 10 years. 

He had an abstinence from alcohol since 2 months. 

GENERAL EXAMINATION:  

Patient is conscious,coherent and cooperative , 

Thin built and poorly nourished .

I'll looking,  sunken eyes , hollowed temporal Fassa, shallow and dry face . 

Generalised muscle wasting present 

Signs of liver failure : 

Alopecia

Palamar erythema :absent 

Dupuytrens contracture : absent 

Flappy tremor :absent 

Gynecomastia: absent 

Lymph node: not  palpable

Loss of body hair seen 

Icterus is present. 

B/L Pedal edema is present. 

Absence of pallor, cyanosis, clubbing, lymphadenopathy. 

VITALS: 

1.Temperature:- 98.4 F 

2.Pulse rate: 84 beats per min, rt radial artery,  regular In rhythm,  normal in volume and character,  no vessel wall thickening 

3.Respiratory rate: 24 cycles per min 

4.BP: 80/60 mm Hg 

5.SpO2: 98% @ Room air  

6.GRBS: 126mg%  

SYSTEMIC EXAMINATION:

EXAMINATION OF A gastrointestinal system : 

Tongue looks yellowish 

Teeth and  gums are  stained 

  P/A: inspection:  abdomen distended ,

no venous prominences over abdomen ,

No visible peristaltic

No visible scars 

Groin :loss of public hair , no scrotal  swe swelling .

Abdomen  moving with respiration. 

No visible Abdominal pulsations . 

Palpation:   temperature: normal tenderness :present in the rt hyppchondrium .

Rigidity :absent 

Guarding : absent 

Abdominal girth: increased .

Hepatojugular reflex positive . 

hepatomegaly and spleenomegaly present.

No palpable lymph nodes 

Testes: small soft and non tender 

Hernia orifices ; intact l 

 Percussion : shiffting dullness + 

 Ascultation : bowel sounds present 

Cvs :

s1 and s2 present. 

Jvp raised . 

Respiratory system : 

B/l air entry present 

Normal.vesicular breath sounds . 

Cns: 

No abnormality detected

ALCOHOLIC LIVER DISEASE WITH GRADE 1 VARICES WITH ACUTE KIDNEY INJURY.

CHILD PUGH  -C

MELD SCORE 31 points

INVESTIGATIONS:

Usg abdomen:

LABS

1. Fluid Restriction < 1.5 lit/day 

  2.Tab PAN 40mg×PO×OD

  3.Tab RIFAXIMINE 550mg×PO×BD

  4.Syp HEPAMERZ 10ml×PO×BD

  5.Syp LACTULOSE 15ml×PO×H/S

  6.Inj Vit-K 10mg×IV×OD

  7.Tab Thiamine 100mg×PO×OD

  8.Tab UDILIV 300mg BD

  9. BP/PR/Temp/SpO2 monitoring 

DISCHARGE SUMMARY :

   Course in the hospital: 

         This is a case of 31 year old male with Chronic Liver Disease with Grade 1 varices with Acute Kidney Injury. Patient was admitted on 14/07/2021. Diagnostic ascitic tap of 1 litre was done and the ascitic fluid was sent for investigation which showed high SAAG and low protein. UGIE showed Grade 1 varices with low grade portal HTN and mild PHG. Patient was treated with Inj. Vit k 10mg, Tab Udiliv 300mg, Tab Rifaximine 550mg, Syp. Hepamerz 10ml, Syp Lactulose, Tab Lasix 20mg, Tab Aldactone 25mg everyday and was advised discharge on 19/7/21.

     Advice at Discharge:

     1. Tab. Udiliv 300mg PO/BD 

     2. Tab. Lasix 20mg PO/BD

     3. Tab Aldactone 25mg PO/BD

     4. Syp Hepamerz 10ml TID 

     5. Syp Lactulose 15ml