1801006052short case

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A 25 year old male patient resident of Yadagirigutta mestri by occupation presented with chief complaints of

Abdominal distension since 6days

Shortness of Breath since 6 days

Yellowish discoloration of sclera since 6days

HISTORY OF PRESENTING ILLNESS:

patient was apparently asyptomatic 4 months back then In April he had fever ,jaundice for 3 days , fever  is not associated with chills and rigor ,no evening rise of temperature he went to hospital , used medication for 1week.

Symptoms subsided  after a week ,he started to consume alcohol(180 ml) daily  since then .

In the month of June he had  Abdominal distension, yellowish decolorisation of sclera , went to a hospital in jangaon took ayurvedic medicine for 1 week , symptoms subsided.

Then he presented on now with complains of Abdominal distension since 6days, Shortness of Breath Gradelll ,fever not associated with Chills and rigor without evening rise of temperature, Altered sleep cycle,facial puffiness,, pedal edema since 3days.

Ascitic tap was done .

PAST HISTORY:

Not a known case of Diabetes mellitus, Hypertension, Epilepsy,Asthma, Tuberculosis, Coronary artery Disease.

No surgeries underwent in the past.

FAMILY HISTORY

 No member of the family has similar complaints.

PERSONAL HISTORY

Appetite- decreased

Diet - Mixed

Bowel& Bladder- Regular

Sleep-Disturbed

Addictions: Alcohol since 10 years  daily 180 ml 

Cigarette 12 / day since 10 years

No known allergies for drugs,food.

GENERAL EXAMINATION:

Patient was conscious, coherent, cooperative poorly bulit and modeately nourished ,

Pallor- cannot be examined due to Yellowish discoloration.

Icterus- present

On the day of admission.

On the next day

cyanosis: Absent

Clubbing: absent

Generalised Lymphadenopathy: Absent

Pedal edema : absent

Vitals:

Temperature

Heart rate:94beats/ min

Blood pressure:118/76 mmHg

Respiratory rate:19 cycles/ min

SYSTEMIC EXAMINATION

Abdomen :

Soft and non tender, Distended.

Inspection: Abdomen distended

 No scars,sinuses.

Umblicus  inverted

No dilated veins

Palpation: All inspectors findings are confirmed Abdomen  is soft and non tender

No visible pulsations

Hepatomegaly

Spleen

Percussion:

Resonant note heard

Shifting dullness present

Auscultation:

Bowel sounds heard.

Respiratory system:

Inspection:

Shape of chest:Barrel shaped

Gynaecomastia present 

A scar present over the rt side

Trachea : central

Wheeze is heard

Palpation:

All inspectors findings are confirmed by palpation

Chest movements: Symmetical

Tactile vocal fremitus

Tidal percussion

Percussion:

Dull note in 6th ICS 

Resonant note in 5th ICS.

Resonant note elsewhere .

Auscultation:

Breath sounds heard.

Cardiovascular system

S1 S2 heard No murmurs.

Central nervous system:

No focal neurological  deficits,all cranial nerves intact .

PROVISIONAL DIAGNOSIS:

Decompensated liver disease with Ascites .

INVESTIGATIONS:

Liver function test:

Prothrombin time:

Activated plasma thromboplastin time:

Renal function test:

Colour Doppler 2D Echo:

ULTRA SOUND OF ABDOMEN:

Ecg:

CHEST X Ray : PA View

Upper GI Endoscopy:

Apraxia Chart:

Ascitic Tap was done on  under aseptic conditions:

TREATMENT:

1. FLUID RESTRICTION.

2. SALT RESTRICTED NORMAL DIET.

3. INJ. CEFOTAXIM 2 GRAM TWICE DAILY INTRAVENOUSLY.

4. INJ. VIT K 1 AMP IN 100 ML NS ONCE DAILY  INTRAVENOUSLY.

5. INJ. THIAMINE 1 AMP IN 100 ML NS ONCE DAILY INTRAVENOUSLY.

6. INJ. PAN 40 MG TWICE DAILY INTRAVENOUSLY.

7. INJ. ZOFER 4 MG THRICE DAILY INTRAVENOUSLY.

8. TAB. PCM 650 mg SOS (<1 GRAM / DAY).

9. SYP. LACTULOSE 15 ML 30 MINUTES BEFORE FOOD THRICE DAILY.