general medicine
G.Pranay kumar rao
3rd semester
# The patient came back to the opd again on 6/8/2021
Case in brief-
A 31YEAR OLD MALE WITH ALCOHOLIC LIVER DISEASE.
Date of admission-14/7/21
Chief Complaints
*Abdominal pain and distension since 7 days
*Pedal edema extending upto knees since 7 days
*Fever since 4 days
HISTORY OF PRESENT ILLNESS:
*Patient was apparently asymptomatic 1 year back then he had pain in abdomen which is of diffuse type(Not associated with vomiting).
*He stopped drinking due to the pain and got treated from local RMP for the pain.
*After the pain has subsided, ,he started to drink again. He had multiple attacks of pain in the abdomen during the past 1 year.
*Two months back he had c/o yellowish discoloration of eyes, pain in the abdomen and b/l pedal edema 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.
*One week back he had non-vegetarian food(mutton) for his dinner, and then developed pain in the abdomen, for which he got treated in the local hospital.
*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.
Treatment history
He has been treated for head injury twice in 2007 and 2014 due to Road traffic accident.
No treatment history for DM, hypertension, asthma, epilepsy, Heart disease or tuberculosis.
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.
Icterus is present.
B/L Pedal edema is present.
Absence of pallor, cyanosis, clubbing, lymp
hadenopathy.
VITALS:
1.Temperature:- 98.4 F
2.Pulse rate: 84 beats per min
3.Respiratory rate: 24 cycles per min
4.BP: 80/60 mm Hg
5.SpO2: 98% @ Room air
6.GRBS: 126mg%
SYSTEMIC EXAMINATION:
CVS:
S1,S2 heard, no murmurs.
RS:
Normal vesicular breath sounds.
EXAMINATION OF ABDOMEN:
Abdomen is distended
No tenderness
CNS:
No focal neurological defect.
PROVISIONAL DIAGNOSIS:
ALCOHOLIC LIVER DISEASE WITH GRADE 1 VARICES WITH ACUTE KIDNEY INJURY.
INVESTIGATIONS:
Hemogram
Liver function tests
RBS
Serum Creatinine
Blood Urea
Serum Electrolytes
HbsAg-Rapid
Ecg
APTT
Prothrombin time
Usg Abdomen
TREATMENT:
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-
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
