Case 1 - 49 years male admission -19/4/23

discharge 24/4/23 admission 19/4/23 49 years male Diagnosis 1) DECOMPENSATED CHRONIC LIVER DISEASE 2) ? HEPATO RENAL SYNDROME 3) GRADE 4 ESOPHAGEAL VARICES 4) INTERNAL HEMORRHOIDS SECONDARY TO PORTAL HYPERTENSION Case History and Clinical Findings C/O ABDOMINAL DISTENSION SINCE 20 DAYS BILATERAL PEDAL EDEMA SINCE 15 DAYS DECREASED URINE OUTPUT SINCE 10 DAYS SHORTNESS OF BREATH SINCE 10 DAYS BLOOD IN STOOLS SINCE SINCE 5 DAYS LOOSE STOOLS SINCE 4 DAYS HISTORY OF PRESENTING ILLNESS : PATIENT WAS APPARENTLY ASYMPTOMATIC 20DAYS AGO ,HE THEN DEVELOPED ABDOMINAL DISTENSION INSIDIOUS IN ONSET AND GRADUALLY PROGRESSIVE TO THE PRESENT SIZE.NO COMPLAINTS OF PAIN ABDOMEN.BILATERAL PEDAL EDEMA SINCE 15 DAYS PITTING TYPE EXTENDING UPTO THE KNEE JOINT.DECRESED URINE OUTPUT SINCE 10 DAYS. NO C/O BURNING MICTURITION. H/O SHORTNESS OF BREATH SINCE 10 DAYS,INSIDIOUS IN ONSET AND GRADUALLY PROGRESSED FROM GRADE 1 TO GRADE 3.SOB INCREASED ON EXERTION AND RELIEVED ON TAKING REST.NO ORTHOPNEA,NO PND. BLOOD IN STOOLS SINCE 5 DAYS,BLOOD AT THE END OF DEFECATION,NOT ASSOCIATED WITH PAIN AND NO MASS PER RECTUM. H/O LOOSE STOOLS SINCE 4 DAYS,4-5 EPISODES/DAY. NO H/O FEVER,VOMITINGS,CHEST PAIN,GIDDINESS. PAST HISTORY : HISTORY OF JAUNDICE IN THE PAST -2 YEARS BACK AND 6 MONTHS BACK AND WAS MANAGED CONSERVATIVELY WITH MEDICATION. K/C/O HTN SINCE 12 YEARS AND ON REGULAR MEDICATION TAB.AMLONG 5MG +TAB.ATENELOL 50MG PERSONAL HISTORY ; DIET : MIXED APPETITE : DECREASED SINCE 20 DAYS SLEEP : NORMAL BOWEL AND BLADDER : DECREASED URINE OUTPUT NO ALLERGIES ALCOHOLIC SINCE 25 YEARS AND STOPPED SINCE 20 DAYS FAMILY HISTORY :INSIGNIFICANT GENERAL EXAMINATION : PATIENT IS CONSCIOUS , COHERENT , COOPERATIVE MODERATELY BUILT AND NOURISHED . ICTERUS AND BILATERAL PEDAL EDEMA PRESENT. NO SIGNS OF PALLOR , CYANOSIS , CLUBBING ,LYMPHADENOPATHY. VITALS : TEMPERATURE: 98.4F PR - 77BPM BP - 110/70 MMHG RR - 20 CPM SPO2 - 97% ON ROOM AIR GRBS - 117 MG% SYSTEMIC EXAMINATION : PER ABDOMEN : INSPECTION : ABDOMEN IS DISTENDED UMBILICUS IS CENTRAL ALL QUADRANTS ARE MOVING EQUALLY WITH RESPIRATION NO SINUSES ,VISIBLE PULSATIONS . PALPATION : NO LOCAL RISE OF TEMPERATURE NO TENDERNESS ABDOMINAL GIRTH 102 CM LIVER AND SPLEEN - NOT PALPABLE PERCUSSION : FLUID THRILL PRESENT SHIFTING DULLNESS ABSENT AUSCULTATION : BOWEL SOUNDS ARE HEARD. CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD. RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS HEARD CENTRAL NERVOUS SYSTEM: NFND PSYCHIATRY REFERREL DONE I/V/O ALCOHOL DEPENDENCE : ADVICE: 1. TAB.PREGABALIN 75MG PO HS 2. PATIENT &OD PSYCHOEDUCATED 3.BREIF PSYCHOTHERAPY DONE. GENERAL SURGERY REFERRAL DONE I/V/O BLOOD IN STOOLS : DIAGNOSIS : INTERNAL HAEMORRHOIDS ?SECONDARY TO PORTAL HYPERTENSION ADVICE :IF BLEED CONTINUES /INCREASES OR SIGNIFICANT DROP IN HEMOGLOBIN ADVICE BANDING OR SCLEROTHERAPY COURSE IN THE HOSPITAL: PATIENT CAME WITH THE ABOVE COMPLAINTS. AFTER EVALUATING HIM CLINICALLY AND WITH APPROPRIATE INVESTIGATIONS, HE WAS FOUND TO HAVE CHRONIC LIVER DISEASE. DIAGNOSTIC AND THERAPEUTIC ASCITIC TAP WAS DONE AND AROUND 800 ML ASCITIC FLUID WAS DRAWN OUT. PSYCHIATRIC REFERREL WAS TAKEN IN VIEW OF ALCOHOL DEPENDENCE AND ADVICE WAS FOLLOWED.SURGERY REFERRAL WAS DONE I/V/O BLOOD IN STOOLS AND THE ADVICE IS FOLLOWED. ENDOSCOPY WAS DONE AND HE IS DIAGNOSED TO HAVE GRADE 4 OESOPHAGEAL VARICES.THERAPEUTIC ASCITIC TAP WAS DONE AGAIN AND AROUD 500ML OF FLUID WAS DRAWN OUT. PATIENT RECOVERED SYMPTOMATICALLY AND DISCHARGED IN STABLE CONDITION. Investigation HEMOGRAM : ON 19/4/2023 HB- 11.1 GM/DL TLC- 9500CELLS/CU.MM PLT-1.25 LAKHS/CU.MM PCV- 34.0 ON 24/4/2023 : HB- 10.5 GM/DL TLC- 5400CELLS/CU.MM PLT-1.6 LAKHS/CU.MM PCV- 32.0 USG ABDOMEN: ? CIRRHOSIS OF LIVER RAISED ECHOGENICITY OF BILATERAL KIDNEYS GROSS ASCITIS SPLENOMEGALY 2D ECHO NO RWMA. NO AS/MS. SCLEROTIC AV TRIVIAL AR +/TR +. NO MR GOOD LV SYSTOLIC FUNTION, MILD LVH +, EF 68% GRADE 1 DIASTOLIC DYSFUNTION +, NO PAH, MINIMAL PE ENDOSCOPY DONE ON 21/4/2023 : GRADE 4 VARICES WITH 4 COLUMNS(HIGH GRADE ESOPHAGEAL VARICES) ASCITIC TAP : SUGAR - 123MG/DL PROTEIN - 1.2G/DL LDH-38IU/L SAAG : SERUM ALBUMIN-2.5G/DL ASCITIC ALBUMIN-0.55G/DL SAAG -1.95 CELL COUNT - 100 CELLS PAUCICELLULAR SMEAR SHOWS PREDOMINANTLY LYMPHOCYTES,FEW MESOTHELIAL CELLS Treatment Given(Enter only Generic Name) INJ.THIAMINE 200MG IN 100ML NS IV OD INJ.PAN 40MG IV OD TAB.UDILIV 300MG PO BD TAB.ALDACTONE 50MG PO OD TAB.SPOROLAC DS PO TID TAB.PREGABALIN 75MG PO HS PROTEIN POWDER 2 TBSP IN A GLASS OF MILK/WATER Advice at Discharge TA.PAN 40MG PO OD BBF TAB.UDILIV 300MG PO BD X 2 WEEKS TAB.ALDACTONE 50MG PO OD X 2 WEEKS TAB.PREGABALIN 75MG PO HS PROTEIN POWDER 2 TBSP IN A GLASS OF MILK/WATER X 2 WEEKS REQUIRES ALBUMIN TRANSFUSION WITH LARGE VOLUME PARACENTESIS/TIPPS I/V/O REFRACTORY ASCITIS.