Case no. 6 65 year old male Admission - 20/12/2023

Case no. 6 65 year old male Admission - 20/12/2023 Discharge - 26/12/2023 Follow up - patient expired Diagnosis CHRONIC DECOMPENSATED LIVER DISEASE; HIGH SAAG LOW PROTEIN ASCITES SECONDARY TO ALCOHOLIC LIVER CIRRHOSIS WITH GRADE 3 ENCEPHALOPATHY B/L LOWER LIMB SWELLING (GRADE III); HYPERVOLUEMIC HYPONATREMIA; HYPOKALEMIA SECONDARY TO CHRONIC LIVER DISEASE; K/C/O CVA- MONOPLEGIA (RIGHT UPPERLIMB) WITH DEVIATION OF MOUTH TO LEFT 15 YEARS AGO . K/C/O DIABETIS MELLITUS 10 YEARS AGO. K/C/O HTN 10 YEARS AGO. Case History and Clinical Findings PRESENTING COMPLAINTS:C/O Abdominal distension and B/L Lower limb swelling since 1 1/2 month.C/O Breathlessness since a month. HOPI:A 65 year male, a potato chip vendor, resident of Bhongiri, was bought to causality with complaints of abdominal distension since 1 1/2 month, gradually progressive, not associated with pain. History of Bilateral lower limb swelling since 1 1/2 month, insidious onset gradually progressive, pitting type of grade 2. History of breathlessness of grade II to III MMRC, since a month, insidious onset, gradually progressive, no seasonal or diurnal variation. No history of chest pain, decreased urine output, PND, Orthopnea, fever, cold, cough. Now admitted for further management and treatment. PAST ILLNESS:History of head injury to occipital region which was self healed, pt had altered behaviour for 6 months.History of CVA - Monoplegia (right upper limb associated with deviation of mouth to left 15 years ago; used anti coagulants for 5 years and stopped.K/C/O HTN since 6 years, on TAB. AMLODIPINE 5mg/PO/OD at 8 AMK/C/O T2DM since 6 years on TAB. GLIMEPIRIDE 2mg+ METFORMIN 1000mg/PO/OD at 8 AM.PERSONAL HISTORY: Decreased appetiteRegular bowel and bladderNo allergiesAlcoholic since the age of 17, takes 160 ML BRANDY till 22 nd sep from 1 st October 90 ml once in 4 days.Smoker since age of 17, initially 36 beedi for a day till 1 st October now 1 beedi per day. COURSE IN THE HOSPITAL: A 65 year male clinically presented with above mentioned complaints. Upon admission after initial examination necessary investigations were done. after explaining the condition and further workup to the patient and his attendees, diagnostic abdominal paracentesis was done, which showed thick straw coloured fluid followed by therapeutic paracentesis was done and sent for analysis. Ascitic fluid: LDH 141 IU/L; Amylase 151 IU/L; Sugar 124 mg/dl; Protein 0.2 mg/dl; Serum Albumin 2.5 mg/dl; Ascitic Albumin 0.11 mg/dl; SAAG 2.49. His serum osmolality 266 mOsm/kg; Spot urinary: Na+ 142 mmol/l; K+ 151 mmol/l; Cl- 176 mmol/l . Hb 10.5 gr/dl; PCV 32.2; TLC 6100 cellsmm3; Platelet count 1.5 lakhs/mm3. He was started on IV Antibiotics, Loop diuretics, Oral Rifiximine, Pottasium supplements and other Liver supportive medications. USG Abdomen was domne on 13/12/2022 which showed: 1. Liver : 12.8 cms , normal size and coarse echotexture, No IHBRD, Gall bladder wall edema (5mm), Portal vein 11mm showing hepatopetal and biphasic pattern. 2. Spleen 2.6 cms with normla size and echotexture, 3. Right kidney of 9.6 * 5.4 cms and Left Kidney 9.3 * 5.2 cms with normal size and echotexture, CMD maibntained and 2d echo findings no rwma mild TR + ,TRIVIAL MR+ DIASTOLIC DYSFUNCTION + NO PE EF 60% MILD AS AND AR POSITIVE IVC SIZE 1 CMS COLLAPSING AT PRESENT HEMOGRAM FINDINGS HB 9.7 TC 10,300 , N/L/M/E/ 90/03/06/01 PCV 30.5 RBC 3.25 ,PLT 1.20 PT 14 ,INR 1.0 ,APTT 29 PATIENT AND PATIENT ATTENDERS HAVE BEEN EXPLAINED ABOUT THE PATIENT CONDITION THAT IS ALTERED SENOSRIUM SECONDARY TO HEPATIC ENCEPHALOPATHY, DIAGNOSED WITH DECOMPENSATED LIVER DISEASE AND VARIOUS COMPLICATIONS THAT MAY ARISE, INCLUDING THE MORTALITY OF THE PATIENT IN THEIR OWN UNDERSTANDABLE LANGUAGE BUT THEY DENIED FURTHER HOSPITAL STAY AND TREATMENT AND UNDER LEAVING AGAINST MEDICAL ADVICE DUE THEIR PERSONAL REASONS. HOSPITAL STAFF, DOCTORS ARE NOT RESPONSIBLE FOR ANY DETORIATION OF THE PATIENT CONDITION Treatment Given(Enter only Generic Name) 1 TAB. RIFAGUT 550MG PO BD 2 TAB. ALDACTONE 50MG PO BD 3 TAB.UDILIV 300MG PO BD 4 TAB. HEPAMERZ 500MG PO OD 5 TAB. AMLONG 5MG PO OD 6 TAB.FOLIC ACID 5MG PO OD 7 TAB.BENFOTHIAMINE 100MG PO BD 8 INJ. HYDROCORT 100MG IV BD 9 INJ. HUMAN ACTRAPID INSULIN S/C TID ACCORDING TO GRBS 10 SYP.POTKLOR 15ML/PO/TID IN 1 GLASS OF WATER 11 INJ.MONOCEF 1GM IV BD 12 SYP.LACTULOSE 30ML PO TID 13 GRBS MONITORING 6TH HOURLY 14 NEB.IPRAVENT 8TH HOURLY Advice at Discharge PATIENT ATTENDERS HAVE BEEN EXPLAINED ABOUT THE PATEINT CONDITION THAT IS ALTERED SENSORIUM SECONDARY TO HEPATIC ENCEPHALOPATHY DIAGNOSED WITH CHRONIC DECOMPENSATED LIVE DISEASE AND VARIOUS COMPLIACTIONS THAT MAY ARISE INCLUDING MORTALITY OF THE PATIENT IN THEIR OWN UNDERSTANDABLE LANGUAGE BUT THEY DENIED FURTHER HOSPITAL STAY AND TREATMENT AND ARE LEAVING AGAINST MEDICAL ADVICE DUE TO THEIR OWN PERSONAL REASONS HOSPITAL STAFF DOCTORS ARE NOT RESPONSIBLE FOR ANY DETORIATION OF PATIENT

Case no. 5 41M admission 21/3/24

Case no. 5 41M admission 21/3/24 discharge 23/3/24 follow up - patient expired Diagnosis SEPTIC SHOCK WITH MODS WITH DIC ALTERED SENSORIUM SECONDARY TO HEPATIC ENCEPHALOPATHY ALCOHOLIC LIVER DISEASE SEVERE ANEMIA SECONARY TO ? GI BLEED S/P ENDOTRACHEAL INTUBATION [DAY-0] ON MECHANICAL VENTILATION Case History and Clinical Findings PT WAS BROUGHT TO CASUALITY IN ALTERED STATE SINCE YESTERDAY MORNING PT WAS APPARENTLY ASSYMPTOMATIC UNTILL YESTERDAY MORNING DEVELOPED ALTERED SENSORIUM , INSIDIOUS ONSET , NOT ORIENTED TO TIME , PLACE , PERSON , CONSCIOUS , NON COOPERATIVE H/O VOMITING 2 EPISODES , GREENISH COLOUR H/O LOOSE STOOL, SINCE 2 DAYS , 4 EPISODES WATERY CONSISTENCY H/O LOSS OF APPETITE SINCE 2 DAYS , H/O INADEQUATE SLEEP SINCE SINCE 3 DAYS NO H/O FEVER , NO H/O DECREASED URINE OUTPUT NO H/O SEIZURE ACTIVITY K/C/O ALCOHOLIC LIVER DISEASE WITH PORTAL HYPERTENSION SINCE 9 MONTHS , STOPPED MEDICATION 10 DAYS BACK N/K/C/O DM, HTN , TB , EPILEPSY , ASTHMA GENERAL EXAMINATION PT CONSCIOUS , INCOHERENT , NON COOPERATIVE AFEBRILE PR-94BPM BP- 130/90 MMHG CVS- S1S2 + RS - BAE + CNS - R L TONE UL + + LL + + POWER - COULDNT ELICIT REFLEXES B +2 +2 T +2 +2 S +2 +2 K +3 +3 A +1 +`1 P E E PUPIL - REACTIVE TO LIGHT COURSE IN HOSPITAL 41 YR OLD MALE WAS BROUGHT TO CASUALITY IN ALTERED STATE , VITALS AT THE TIME OF ADMISSION PT CONSCIOUS , INCOHERENT , NON COOPERATIVE , PR -94BPM , BP- - 130/70 MMHG , GRBS- 139 MG/DL , SPO2 - 98% ON RA , PT WAS EVALUATED ACCORDINGLY AND DIAGNOSED AS ALTERED SENSORIUM SECONDARY TO ALCOHOLIC LIVER DISEASE , PT WAS TREATED ACCORDINGLY COAGULATION PROFILE WAS DERANGED SO 6. PACKETS OF FFP WERE TRANSFUSED AND DUE TO FALLING HB 1 PACKET PRBC WAS TRANSFUSED , MRI WAS DONE I/V/O INTRACRANIAL HEMORRHAGES NO ABNORMALITY WAS DETECTED ,ON DAY 3 MORNING ENDOTRACHEAL INTUBATION WAS DONE I/V/O FALLING SATURATIONS AND LOW GCS AND TREATMENT WAS CONTINUED ACCORDINGLY . PT ATTENDERS WERE EXPLAINED ABOUT THE CONDITION OF THE PT AND NEED FOR FURTHER TREATMENT AND STAY IN THE HOSPITAL BUT PT ATTENDERS ARE NOT WILLING TO STAY AND WANT TO LEAVE AGAINST MEDICAL ADVICE . Investigation POST LUNCH BLOOD SUGAR 21-03-2024 11:33:AM 134 mg/dl 140-0 mg/dlSERUM CREATININE 21-03-2024 11:33:AM 1.0 mg/dl 1.3-0.9 mg/dlBLOOD UREA 21-03-2024 11:33:AM 70 mg/dl 42-12 mg/dlLIVER FUNCTION TEST (LFT) 21-03-2024 11:33:AMTotal Bilurubin 19.30 mg/dl 1-0 mg/dlDirect Bilurubin 10.4 mg/dl 0.2-0.0 mg/dlSGOT(AST) 411 IU/L 35-0 IU/LSGPT(ALT) 115 IU/L 45-0 IU/LALKALINE PHOSPHATASE 201 IU/L 128-53 IU/LTOTAL PROTEINS 6.1 gm/dl 8.3-6.4 gm/dlALBUMIN 3.0 gm/dl 5.2-3.5 gm/dlA/G RATIO 0.96HBsAg-RAPID 21-03-2024 11:33:AM NegativeAnti HCV Antibodies - RAPID 21-03-2024 11:33:AM Non ReactiveSERUM ELECTROLYTES (Na, K, C l) 21-03-2024 11:35:AMSODIUM 134 mmol/L 145-136 mmol/LPOTASSIUM 4.0 mmol/L 5.1-3.5 mmol/LCHLORIDE 103 mmol/L 98-107 mmol/LCOMPLETE URINE EXAMINATION (CUE) 21-03-2024 06:54:PMCOLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN NilSUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 10-20EPITHELIAL CELLS 3-4RED BLOOD CELLS loadedCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Bacteria seenLIVER FUNCTION TEST (LFT) 22-03-2024 12:07:AMTotal Bilurubin 19.62 mg/dl 1-0 mg/dlDirect Bilurubin 14.22 mg/dl 0.2-0.0 mg/dlSGOT(AST) 325 IU/L 35-0 IU/LSGPT(ALT) 114 IU/L 45-0 IU/LALKALINE PHOSPHATASE 190 IU/L 128-53 IU/LTOTAL PROTEINS 6.1 gm/dl 8.3-6.4 gm/dlALBUMIN 3.08 gm/dl 5.2-3.5 gm/dlA/G RATIO 1.02STOOL FOR OCCULT BLOOD 22-03-2024 12:08:AM Positive (+ve)COMPLETE URINE EXAMINATION (CUE) 22-03-2024 04:18:PMCOLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN NilSUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 2-3EPITHELIAL CELLS fewRED BLOOD CELLS 4-5CRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Bacteria seenBLOOD UREA 22-03-2024 11:46:PM 113 mg/dl 42-12 mg/dlSERUM CREATININE 22-03-2024 11:46:PM 1.4 mg/dl 1.3-0.9 mg/dlSERUM ELECTROLYTES (Na, K, C l) 22-03-2024 11:46:PMSODIUM 139 mmol/L 145-136 mmol/LPOTASSIUM 3.1 mmol/L 5.1-3.5 mmol/LCHLORIDE 98 mmol/L 98-107 mmol/LLIVER FUNCTION TEST (LFT) 22-03-2024 11:46:PMTotal Bilurubin 19.81 mg/ dl 1-0 mg/dlDirect Bilurubin 12.85 mg/dl 0.2-0.0 mg/dlSGOT(AST) 299 IU/L 35-0 IU/LSGPT(ALT) 111 IU/L 45-0 IU/LALKALINE PHOSPHATASE 125 IU/L 128-53 IU/LTOTAL PROTEINS 5.5 gm/dl 8.3-6.4 gm/dlALBUMIN 2.88 gm/dl 5.2-3.5 gm/dlA/G RATIO 1.10ABG 23-03-2024 03:24:AMPH 7.382PCO2 16.6PO2 110HCO3 9.6St.HCO3 12.3BEB -15.1BEecf -14.7TCO2 21.9O2 Sat 98.6O2 Count 4.6ABG 23-03-2024 09:20:AMPH 7.39PCO2 19.2PO2 222HCO3 11.4St.HCO3 14.0BEB -12.9BEecf - 12.6TCO2 25.8O2 Sat 99.7O2 Count 5.8 CBP-21/3/24 HB- 6.2 TC- 7200 PCV- 16.9 CBP- 22/3/24 HB- 4.8 TC- 6000 PLT-40000 LDH- 139 RETIC COUNT- 0.9 TROP I - 48.6 USG- ABDOMEN AND PELVIS PORTAL HYPERTENSION MILD SPLENOMEGALY GRADE 2 FATTY LIVER MILD ASCITES [ FEW MESENTRIC COLLATERALS NOTED IN RT HYPOCHONDRIUM ] 2D ECHO NO RWMA EF-68% GOOD LV SYSTOLIC FUNCTION NO DIASTOLIC DYSFUNCTION IVC - 1.08 COLLAPSING SCLEROTIC AV MRI - BRAIN - NO ABNORMALITY DETECTED SERUM LACTATE -23.3 Treatment Given(Enter only Generic Name) GIVEN RT FEEDS 2ND HRLY IVF NS @ 50 ML/HR INJ . NORAD 10.16 MGS /ML @ 12 ML /HR TO MAINTAIN MAP >65 INJ. DOBUTAMINE 15 MG ML @ 3.2 ML /HR TO MAINTAIN MAP INJ.VASOPRESSIN 2ML /HR INJ . CEFOTAXIME 2GM IV BD INJ VIT K 1 AMP IV OD INJ .MEROPENEM IV 1GM BD INJ. METROGYL IV TID INJ.PAN 40 MG IV /OD INJ .THIAMINE 250 G IV BD INJ. ATRACURIUM [1MG/ML] @ 5 ML /HR INJ. TRANEXAMIC ACID 1GM IV BD INJ . OCTREOTIDE 50 MG IV TIA T.RIFAGUT 550 MG RT BD T.UDILIV 300 MG RT BD T.CARDIVAS 3.125 MG RT OD SYP .LACTULOSE 15 MG RT BD SYP. HEPAMERZ 20 ML RT TID Advice at Discharge PT ATTENDERS HAVE BEEN EXPLAINED ABOUT THE CONDITION OF PT I.E SEPTIC SHOCK WITH MODS WITH DIC . ALTERED SENSORIUM SECONDARY TO HEPATIC ENCEPHALOPATHY , ALCOHOLIC LIVER DISEASE , SEVERE ANEMIA S/P ET INTUBATION [ DAY-0] ON MECHANICAL VENTILATION AND COMPLICATION A/W IT I.E RISK OF DEATH , AND NEED FOR FURTHER MANAGEMENT AND HOSPITAL STAY . BUT PT ATTENDER ARE NOT WILLING TO STAY AND WANT TO LEAVE AGAINST MEDICAL ADVISE ,. DOCTOR AND HOSPITAL ARE NOT RESPONSIBLE FOR ANY UNTOWARD EVENT

Case-4 59M admission 09/01/24

59 years male admission -09/01/24 discharge 12/01/24 Diagnosis CHRONIC DECOMPENSATED ALCOHOLIC LIVER DISEASE WITH THROMBOCYTOPENIA Case History and Clinical Findings C/O B/L PEDAL EDEMA SINCE 5DAYS FACIAL PUFFINESS 4DAYS TREMORS IN B/L UPPER LIMBS SINCE 1YR CHEST THIGHTNESS SINCE 10DAYS PT WAS APPARENTLY ASYMPTOMATIC 5DAYS BACK THEN HE DEVELOPED B/L PEDAL EDEMA PITTING TYPE UPTO KNEE INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE AGGRAVATED ON WALKING AND NO RELIEVING FACTORS A/W FACIAL PUFFINESS SINCE 4 DAYS H/O TREMORS SINCE 1YR H/O CHEST THIGHTNESS SINCE 10DAYS NO SIMILAR COMPLAINTS IN PAST NO KNOWN COMORBIDITIES. \ PALLOR, ICTERUS, CUBBING, CYANOSIS, LYMPHADENOPATHY,EDEMA- ABSENT VITALS- TEMPERATURE AFEBRILE RR-24CPM PR- 72BPM BP-90/60MMHG SPO2-95% SYSTEMIC EXAMINATION: CVS- S1 S2 HEARD, NO ADDED MURMURS. RS- BAE+, NORMAL VESICULAR BREATH SOUNDS CNS - NO FOCAL NEUROLOGICAL DEFICIT. P/A- SOFT, NON TENDER, NO ORGANOMEGALY. USG DONE ON 9/1/24 COARSE ECHOTEXTURE OF LIVER WITH IRREGULAR SURFACE MILD ASCITES F/S/O CHRONIC LIVER DISEASE GASTRO REFERAL WAS DONE ON 12/1/24 ADV: TAB NUSAM 400MG Investigation NameValueRangeNameValueRangeCOMPLETE URINE EXAMINATION (CUE) 09-01-2024 11:15:AM COLOURPale yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMINNilSUGARNilBILE SALTSNilBILE PIGMENTSNilPUS CELLS2-3EPITHELIAL CELLS1-2RED BLOOD CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilLIVER FUNCTION TEST (LFT) 09-01-2024 11:16:AM Total Bilurubin1.54 mg/dl1-0 mg/dlDirect Bilurubin1.32 mg/dl0.2- 0.0 mg/dlSGOT(AST)53 IU/L35-0 IU/LSGPT(ALT)23 IU/L45-0 IU/LALKALINE PHOSPHATE490 IU/L128-53 IU/LTOTAL PROTEINS8.5 gm/dl8.3-6.4 gm/dlALBUMIN3.25 gm/dl5.2-3.5 gm/dlA/G RATIO0.62RFT 09-01-2024 11:16:AM UREA39 mg/dl42-12 mg/dlCREATININE1.0 mg/dl1.3-0.9 mg/dlURIC ACID5.2 mg/dl7.2-3.5 mg/dlCALCIUM9.8 mg/dl10.2-8.6 mg/dlPHOSPHOROUS3.2 mg/dl4.5-2.5 mg/dlSODIUM138 mEq/L145-136 mEq/LPOTASSIUM3.6 mEq/L5.1-3.5 mEq/LCHLORIDE102 mEq/L98-107 mEq/LCOMPLETE URINE EXAMINATION (CUE) 09-01-2024 05:57:PM COLOURPale yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMINNilSUGARNilBILE SALTSNilBILE PIGMENTSNilPUS CELLS2-3EPITHELIAL CELLS2-3RED BLOOD CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilHBsAg-RAPID09- 01-2024 05:57:PMNegative Anti HCV Antibodies - RAPID09-01-2024 05:57:PMNon Reactive T3, T4, TSH 09-01-2024 06:47:PM T30.86 ng/ml1.87-0.87 ng/mlT48.86 micro g/dl12.23-6.32 micro g/dlTSH4.13 micro Iu/ml5.36-0.34 micro Iu/mlBLOOD UREA10-01-2024 10:18:PM26 mg/dl42-12 mg/dlSERUM CREATININE10-01-2024 10:18:PM1.6 mg/dl1.3-0.9 mg/dlSERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 10-01-2024 10:18:PM SODIUM140 mEq/L145-136 mEq/LPOTASSIUM4.0 mEq/L5.1-3.5 mEq/LCHLORIDE104 mEq/L98-107 mEq/LCALCIUM IONIZED1.20 mmol/Lmmol/L Treatment Given(Enter only Generic Name) INJ THIAMINE 200MG IV/BD IN 100ML NS INJ PAN 40MG IV/OD TAB LACILACTONE 20/50 PO/BD TAB UDILIV 300MG PO/OD SYP LACTULOSE 10ML PO/BD Advice at Discharge TAB BENFOMATE FORTE 200MG PER ORAL ONCEDAILY X 5 DAYS TAB PAN 40MG PER ORAL ONCE DAILY X 5 DAYS TAB LACILACTONE 20/50 PER ORAL TWICE DAILY X 5 DAYS TAB UDILIV 300MG PER ORAL ONCE DAILY X 5 DAYS TAB NUSAM 400MG PER ORAL TWICE DAILY X 5 DAYS SYP LACTULOSE 10ML PER ORAL TWICE DAILY Follow Up FOLLOW UP AFTER 1 WEEK OR SOS

Case no.3 39 year old male admission 02/10/23

39 years old male Case no. 3 Admission date 02/10/2023 Discharge date 06/10/23 Diagnosis DECOMPENSATED CHRONIC LIVER DISEASE SECONDARY TO ALCOHOL SUBACUTE BACTERIAL PERITONITIS ANEMIA SECONDARY TO NUTRITIONAL ? B12 DEFICIENCY Case History and Clinical Findings C/O PAIN ABDOMEN YELLOWISH DISCOLORATION OF EYES ABDOMINAL DISTENSION PEAL EDEMA SINCE ONE MONTH HOPI : PATIENT WAS APPARENTLY ALRIGHT 1 MONTH BACK THEN HE HAD PAIN ABDOMEN IN THE EPIGASTRIC REGION AND UMBILICAL REGION WHICH IS TWISTING TYPE OF PAIN , NON RADIATING , NOT AOCIATED WITH NAUSEA , VOITINGS , OR LOOSE STOOLS ABDOMINAL DISTENSION SINCE ONE MONTH PEDAL EDEMA SINCE 1 MONTH WHICH IS PITTING TYPE FEVER + SINCE 1O DAYS , LOW GRADE , ONLY EVENING RISE OF TEMPERATURE NO CHEST PAIN , SOB , PALPIATIONS . NO MALENA , HEMATURIA , HEMATEMESIS PAST HISTORY : N/K/C/O DM , HTN , THYROID DIORDERS , CVA , CAD PERSONAL HISTORY: MIXED DIET APPETITE IS NORMAL BOWEL AND BLADDER - REGULAR ADDICTIONS: ALCOHOLIC SNCE 20 YEARS [DAILY 90ML} GENERAL EXAMINATION: PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE PALLOR+ NO SIGNS OF PALLOR,ICTERUS,CLUBBING,CYANOSIS ,LYMPHADENOPATHY,EDEMA VITALS- TEMP- 98.5 PR- 98 BPM RR- 18CPM BP-110/60MMHG SPO2- 98% AT RA NO CHEST PAIN , SOB , PALPIATIONS . NO MALENA , HEMATURIA , HEMATEMESIS Investigation HB : 7.1 PCV : 21.2 TLC : 5000 RBC : 2.04 PLATEELET COUNT : 1.5 PT : 18 SECINRV: 1.33 APTT : 35 SEROLOGY : NEGATIVE RBS : 142 RFT : UREA : 21 CREATININE : 0.8 2/10/23 4/10/23 NA : 136 137 K : 3.7 3.8 CL: 98 104 LFT : 2/10/23 3/10/23 TB: 3.17 2.40 DB : 1,.64 1.94 AST:58 47 ALT : 28 22 ALP :263 251 TP :6.2 6.4 ALBUMIN : 2.2 2.76 A/G : 0.55 0.76 CA IONIZED : 1.01 1.20 ASCITIC FLUID CYTOLOGY : SHOWS PREDOMINANTLY DEGENERATED NEUTROPHILS , FEW LYMPHOCYTES , MESOTHELIAL CELLS IN AN PROTIACIOUS BACKGROUND NO EVIDENCE OF ATYPICAL CELLS ASCITIC FLUID SUGAR- 171 MG/DL ASCITIC FLUID PROTEIN- 1.5 GM/DL ASCITIC FLUID LDH-207 IU/L CELL COUNT OF ASCITIC FLUID: APPEARS CLEAR COLOR-PALE YELLOW TOTAL COUNT-300 CELLS/CUMM NEUTROPHILS-70% LYMPHOCYTES- 30% RBC-NIL FEW MESOTHELIAL CELLS SEEN VOLUME - 2ML SERUM ALBUMIN - 2.2 GM/DL ASCITIC ALBUMIN - 0.4 GM/DL SAAG- 1.8 Treatment Given(Enter only Generic Name) 1. FLUID RESTRICTION <1.5 LITRES /DAY 2. SALT RESTRICTION <2 G /DAY 3. INJ PAN 40 MG IV /OD 4. INJ CEFOTAXIME 2 GM IV /TID X 4DAYS 5.INJ VITCOFOL 2500 MG IM/OD X 6.TAB . LASIX 20 MG PO /BD 7.TAB.UDILIV 300 MG PO/BD 8.TAB.BENFOMET PLUS PO /BD 9.2-3 EGG WHITES /DAY Advice at Discharge 1. FLUID RESTRICTION <1.5 LITRES /DAY 2. SALT RESTRICTION <2 G /DAY 3. TAB.PAN 40 MG IV /OD X 3 DAYS 4.TAB.TAXIM 200MG PO/BD X 3 DAYS 5.TAB.LASIX 20MG PO/BD X 1 WEEK 6.INJ.VITCOFOL (2500MG) ALTERNATE DAY X 1 WEEK WEEKLY ONCE X 1 MONTH MONTHLY ONCE X 3MONTHS 7.TAB.UDILIV 300 MG PO/BD X 1 WEEK 8.TAB.BENFOMET PLUS PO /BD X 1 WEEK 9.2-3 EGG WHITES /DAY On Follow up - patient reported he is doing fine

Case 2 46yr male admission 28/04/23

discharge 03/05/23 39 years old male Case no. 3 Admission date 02/10/2023 Discharge date 06/10/23 Diagnosis DECOMPENSATED CHRONIC LIVER DISEASE SECONDARY TO ALCOHOL SUBACUTE BACTERIAL PERITONITIS ANEMIA SECONDARY TO NUTRITIONAL ? B12 DEFICIENCY Case History and Clinical Findings C/O PAIN ABDOMEN YELLOWISH DISCOLORATION OF EYES ABDOMINAL DISTENSION PEAL EDEMA SINCE ONE MONTH HOPI : PATIENT WAS APPARENTLY ALRIGHT 1 MONTH BACK THEN HE HAD PAIN ABDOMEN IN THE EPIGASTRIC REGION AND UMBILICAL REGION WHICH IS TWISTING TYPE OF PAIN , NON RADIATING , NOT AOCIATED WITH NAUSEA , VOITINGS , OR LOOSE STOOLS ABDOMINAL DISTENSION SINCE ONE MONTH PEDAL EDEMA SINCE 1 MONTH WHICH IS PITTING TYPE FEVER + SINCE 1O DAYS , LOW GRADE , ONLY EVENING RISE OF TEMPERATURE NO CHEST PAIN , SOB , PALPIATIONS . NO MALENA , HEMATURIA , HEMATEMESIS PAST HISTORY : N/K/C/O DM , HTN , THYROID DIORDERS , CVA , CAD PERSONAL HISTORY: MIXED DIET APPETITE IS NORMAL BOWEL AND BLADDER - REGULAR ADDICTIONS: ALCOHOLIC SNCE 20 YEARS [DAILY 90ML} GENERAL EXAMINATION: PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE PALLOR+ NO SIGNS OF PALLOR,ICTERUS,CLUBBING,CYANOSIS ,LYMPHADENOPATHY,EDEMA VITALS- TEMP- 98.5 PR- 98 BPM RR- 18CPM BP-110/60MMHG SPO2- 98% AT RA NO CHEST PAIN , SOB , PALPIATIONS . NO MALENA , HEMATURIA , HEMATEMESIS Investigation HB : 7.1 PCV : 21.2 TLC : 5000 RBC : 2.04 PLATEELET COUNT : 1.5 PT : 18 SECINRV: 1.33 APTT : 35 SEROLOGY : NEGATIVE RBS : 142 RFT : UREA : 21 CREATININE : 0.8 2/10/23 4/10/23 NA : 136 137 K : 3.7 3.8 CL: 98 104 LFT : 2/10/23 3/10/23 TB: 3.17 2.40 DB : 1,.64 1.94 AST:58 47 ALT : 28 22 ALP :263 251 TP :6.2 6.4 ALBUMIN : 2.2 2.76 A/G : 0.55 0.76 CA IONIZED : 1.01 1.20 ASCITIC FLUID CYTOLOGY : SHOWS PREDOMINANTLY DEGENERATED NEUTROPHILS , FEW LYMPHOCYTES , MESOTHELIAL CELLS IN AN PROTIACIOUS BACKGROUND NO EVIDENCE OF ATYPICAL CELLS ASCITIC FLUID SUGAR- 171 MG/DL ASCITIC FLUID PROTEIN- 1.5 GM/DL ASCITIC FLUID LDH-207 IU/L CELL COUNT OF ASCITIC FLUID: APPEARS CLEAR COLOR-PALE YELLOW TOTAL COUNT-300 CELLS/CUMM NEUTROPHILS-70% LYMPHOCYTES- 30% RBC-NIL FEW MESOTHELIAL CELLS SEEN VOLUME - 2ML SERUM ALBUMIN - 2.2 GM/DL ASCITIC ALBUMIN - 0.4 GM/DL SAAG- 1.8 Treatment Given(Enter only Generic Name) 1. FLUID RESTRICTION <1.5 LITRES /DAY 2. SALT RESTRICTION <2 G /DAY 3. INJ PAN 40 MG IV /OD 4. INJ CEFOTAXIME 2 GM IV /TID X 4DAYS 5.INJ VITCOFOL 2500 MG IM/OD X 6.TAB . LASIX 20 MG PO /BD 7.TAB.UDILIV 300 MG PO/BD 8.TAB.BENFOMET PLUS PO /BD 9.2-3 EGG WHITES /DAY Advice at Discharge 1. FLUID RESTRICTION <1.5 LITRES /DAY 2. SALT RESTRICTION <2 G /DAY 3. TAB.PAN 40 MG IV /OD X 3 DAYS 4.TAB.TAXIM 200MG PO/BD X 3 DAYS 5.TAB.LASIX 20MG PO/BD X 1 WEEK 6.INJ.VITCOFOL (2500MG) ALTERNATE DAY X 1 WEEK WEEKLY ONCE X 1 MONTH MONTHLY ONCE X 3MONTHS 7.TAB.UDILIV 300 MG PO/BD X 1 WEEK 8.TAB.BENFOMET PLUS PO /BD X 1 WEEK 9.2-3 EGG WHITES /DAY On Follow up patient reported he is doing fine

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.

40M CLD(1month

New admission 

Amc bed 2

40/M

C/o abdominal distension and SOB since 3 days. Similar complaints 1month back and admitted in hospital due to icterus. Managed conservatively. N/k/c/o HTN, DM, CVA,CAD. 

Diag: Decompensated chronic liver disease.