65 YEAR OLD MALE WITH DISTENDED ABDOMEN



65 YEAR OLD MALE WITH DISTENDED ABDOMEN

September 26, 2022

 Elog 
   26th sept 2022

This is an online E-log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through a series of inputs available global online community of experts with the aim to solve the patient’s clinical problems with the collective current best evidence based inputs. This E log reflects my patient centred online learning portfolio and your valuable inputs in the comments section

Chief complaint

1. SOB since 2 years
2. Distended abdomen since 6 months
3. Swollen legs since ?

History of present illness 

Patient was apparently asymptomatic 2 years ago when he developed SOB which didnot hinder his daily activities so the patient didn't recieve any treatment 
6 months back, the patient was having a distended abdomen and was experiencing sob even after a short walk for which he visited a local hospital where he was administered glucose and recieved 2 units of blood transfusion
His SOB and edema in legs and the abdominal distention aggravated since 15 days, patient started experiencing sob even on sitting 
He also had diarrhea since 4 days
Fever since 3 days, according to the patient, temperature was apparently high during the day and reduced during the evening time

History of past illness 

1. DM since 2 years, for which medication(metformin) was used only for an year and later refused to take any medicine
2. HTN since 2 years 
3. 25 to 30 years back the patient apparently fell from the train and had a major crack in the skull for which he didnot recieve any surgery?
Following the injury, the patient's speech was apparently incoherent or not making any sense for one year 
4. 12 years back he had an episode of paralysis in his right upper limb for which he was initially given 2 injections on the same day at a hospital in Hyderabad which relieved his attack and further used ayurvedic medicine for 5 years (but the course given was for only 3 years)

Personal history 
Appetite - REDUCED 
Sleep - DISTURBED 
Bowel movements  - Normal
Micturition - normal
Alcohol intake -- regular consumption of whiskey since 40 years
 (death of his wife 20 years back and death of his son 5 years back lead to further increase in the frequency of alcohol consumption)
Smoking ?
Drugs ?

Family history 
Mother and  brother had DM

Surgical history 
NO HISTORY OF SURGERIES
was denied knee surgery due to his head injury in the past

Treatment history 
● Metformin was prescribed for diabetes which he used only for an year
●Medication for hypertension was also prescribed since 2 years
●Takes B complex tablets occasionally whenever he notices fissures on his toungue
●Recieved 2 units of blood transfusion 6 months back
●Has been on ayurvedic medication for 5 years which was prescribed for 3 years for his paralysis 

GENERAL EXAMINATION
Pallor - present 
Icterus - absent
Cyanosis - absent
Kolionychia - absent 
Lymphadenopathy - absent
Edema - Present (pitting type of edema)(grade 2?)


Reports



Ascitic fluid protien sugar
PROVISONAL DIAGNOSIS: 
CHRONIC LIVER DISEASE 

TREATMENT 

DAY 1

Inj Lasix 40 mg IV BD

Tab aldactone 50mg PO OD

Tab UDILIV 300mg

Tab HEPAMERZ 500mg

Inj HAI

Lactulose 15ml

GRBS monitored 6th hourly 

Foley's catheterization 

Inj THIAMINE 200mg in 50ml NS IV BD

Inj VIT K in 50 ml NS

Fluid restriction <1.5 lts/day



DAY 2

Inj LASIX 40mg

Inj VIT K 10 ml

Inj THIAMINE 200 mg

Tab ALDACTONE 50 mg

Tab RIFAGUT 550 mg

Tab HEPAMERZ 500mg

Syp LACTULOSE 15ml

Syp POTCHLOR 10ml





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