Skip to main content

A 48 YEAR OLD MALE



UNIT 3 ADMISSION 

A 48 yr old male,came to casualty with 

CHIEF COMPLAINTS OF :

: Abdominal distention &
: Umbilical hernia with discharging pus since 1day

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic 1 day back.then he developed

1.Abdominal distension extending to xiphisternum.because of increased distension & itching sensation, patient scratched umbilical hernia.for which tearing was there in hernia & discharge of ascitic fluid present.
2. Ascitic fluid leak from the umbilical sinus - 1 day

PAST HISTORY: 

Presence of similar complaints in past, for which  he got admitted on 23rd june 2021
https://shriyaayuthumedicinerollno13.blogspot.com/2021/06/chronic-alcoholic-liver-disease-with.html?m=1

Patient is a chronic alcoholic since 20 yrs

-4 yrs back, had complaints of
1.Ascites
2.Pedal edema
3.NEGATIVE HISTORY: No decreased urine output, No SOB

-2 yrs back, increased symptoms of
1.Pedal edema
2.Ascites
3.Vomiting(1 episode)
4.Associated with decreased appetite & weight
5.NEGATIVE HISTORY: No SOB
- Due to increased symptoms, patient got admitted in sunshine hospitals.
- 1 episode of ascitic tap done
- Used medications for 1 yr after ascitic tap along with alcohol drinking

-1 yr back
1.Melena (1 episode)
2.Pedal edema (both legs)
3.Leg pain
4.Ascites
5.Associated with decreased appetite
6.NEGATIVE HISTORY: No pain abdomen

- 4 months back, patient noticed 
1.Umbilical hernia
2.Increased symptoms
- 1 episode of ascitic tap done

- 2 months back( june 23rd ), had increased symptoms of
1.Ascites
2.SOB 
- 1 episode of ascitic tap done

- 1 day back, got admitted in casualty for 
1.Abdominal dimension
2.Discharge of ascitic fluid

-Patient is a known case of chronic alcoholic liver disease with portal hypertension

-Appendectomy 25 yrs back

-Not a known case of HTN,DM,Thyroid,Asthma,Epilepsy 

FAMILY HISTORY :
No significant history 

PERSONAL HISTORY :
Diet : mixed
Appetite : Normal
Sleep : inadequate 
Addiction : chronic alcoholic 
                    Toddy two bottles daily 
                    Alcohol - 90 ml per day
Last drink - 3 days back

GENERAL EXAMINATION:

Patient is conscious, coherent, cooperative. 
No pallor 
No icterus 
No clubbing, cyanosis 
No koilonychia
No lymphadenopathy
No Edema 
Tremors - +
Small lesions - +

Vitals
Temperature : afebrile
Respiratory rate : 26cpm
Blood pressure : 120/70 mmHg
Pulse :82bpm


Per Abdomen :

-Distended abdomen
-Scars present 
-Engorged veins are seen
-Umbilical hernia present 
-Fluid thrill present 
-Multiple excoriation marks - +
-Gross ascites is seen
-Abdominal girth - 98 cm
-Distance between Xiphisternum and Umbilicus - 9.5 cm
-Distance between Umbilicus and Pubictubercle - 5.5 cm

RESPIRATORY SYSTEM:
BAE+ 
NVBS 

CVS :
 S1S2 HEARD 
no thrills no murmurs

CNS:
All superficial and deep reflexes are normal

PROVISIONAL DIAGNOSIS:
Chronic liver disease with portal hypertension

INVESTIGATIONS:

RBS

BLOOD UREA


SR.CREATININE

SR.ELECTROLYTES


LFT


HEMOGRAM 

RTPCR

PT

APTT

SAAG

ASCOTIC FLUID FOR LDH

ASCITIC FLUID FOR PROTEIN SUGAR

CUE


USG ABDOMEN: 

CHEST X RAY

ECG

ASCITIC FLUID:




TREATMENT:

1.TAB PAN 40mg X PO X OD
2.TAB RIFAGUT 550mg X PO X BD
3.SYP LACTULOSE X 10ml X H/S
4.SYP HEPAMERZ X 10ml X BD
5.T.LASILACTONE/PO/OD
6.Daily abdominal girth measurement
7.Daily weight measurement
8.Strict charting

Comments

Post a Comment

Popular posts from this blog

A 28 YR OLD MALE

UNIT 3 ADMISSION  A 28y old male came to the opd with chief complaints of fever since 10 to 25  days and SOB since 5 to 6 days. Patient was apparently asymptomatic 15 days back then developed fever which was incidious in onset and non progressive. It was associated with chills and dry cough. Not associated with cold. C/O SOB since 5 to 6 days that progressed from grade 2 to grade 3. Not associated with pedel edema and loose stools. No h/o bleeding manifestations, bleeding gums, malena, hemoptysis, hemetemesis. PAST HISTORY: No h/o similar complaints of in the past. No h/o DM, HTN, CAD, Asthma, TB. PERSONAL HISTORY : Patient has a mixed diet with decreased appetite and adequate sleep. Patient has constipation. Normal bladder filling and micturition. No addictions. No significant family history. GENERAL EXAMNATION: Patients is c/c/c. No pallor, icterus, cyanosis, clubbing, Vital2s lymphadenopathy, pedel edema. VITALS: temp: 101 F PR: 98 bump nd  RR: 18 cpm. BP: 90/70 mmhg. ...
Post a Comment
Read more

A 73 yr old male

Unit 3 admission  http://sriramkk2k.blogspot.com/2021/08/case-of-74-year-old-male.html ICU : 1st bed A 74 yr old male, retired RTC driver(11 yrs back), resident of narketpally came to the casuality with Complaints of 1.Fever since 3 days 2.Decreased urineoutput since 2 days 3.SOB GRADE : 3 since 1 day HOPI 1.FEVER: - Sudden in onset, associated with chills, incresed during nights &  relieved on medications.fever spikes increased after connecting urinebag before 2 days 2.DECREASED URINE OUTPUT: - Normal frequency was 4 times/day & 3 times/night.since 2 days from tuesday morning, output decreased.they went to local RMP at night 10pm of tuesday  & urine bag was connected by local RMP. 3.SOB GRADE : 3  - Present while walking & at rest also PAST HISTORY: - Pt was apparently asymptomatic 2 months back, was admitted & diagnosed in our hospital with lt facial nerve palsy, peripheral neuropathy(? ATT INDUCED), denovo HTN (? post pulmo tb),Spondyloarthropa...
Post a Comment
Read more

A 22 YR OLD MALE

Unit 3 admission  A 22yr old  male,resident of Palleria village, atmakur mandal case to OPD with  COMPLAINTS OF: 1.Weakness of Bilateral lower limbs since 1week causing unable to walk 2. Fever 5 days back lasted for 3 days HOPI : A 22 yr male intellectually disable confined to running errands at home was brought to OPD  1.WEAKNESS: - Sudden in onset, gradually progressive intially in B/L lower limbs and then progressed to upper limbs - Weakness is more in distal portion of limbs compared to proximal region - Pt is able to roll on bed - Get up from bed from supine position  - Able to perceive the sensation of clothes  - Slippage of foot absent while wearing slippers  - No bowel & bladder incontinence  10 days back patient had attended  a ceremony at relative place & Taken food & drank 1 lit of toddy.after which later in the evening, he developed 2. FEVER : - Low grade,not associated with chills & rigors - Developed cold along w...
Post a Comment
Read more