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 40 YR OLD MALE

Unit 6 admission  A 48 yr old male, farmer by occupation & resident of Nakrekal.came to casualty with CHEIF COMPLAINTS: 1.Fever since 1wk 2.Swelling in the right lower limb since 4 days 3.Pain over the swelling since 2 days 4.Loose stools  since 4 days (4 episodes/day) HISTORY OF PRESENT ILLNESS  : pt was apparently asymptomatic 1 wk back then, he developed  1. FEVER : - low grade, intermittent type, associated  with chills & rigors & relieved by medications. - pt is k/c/o Rt lower limb filariasis since 20 yrs - Due to filariasis, pt used to have fever spikes for every 6 months since 20 yrs. for which he used to take medications & fever relieved - Recently After 3 yrs, he again had a bout of fever spikes since 1 wk.for which he got admitted to a local hospital in nakrekal and took medications. & also found decrease of platelet count 2. SWELLING IN THE RIGHT  LOWER LIMB :  - pt had trauma over rt lower limb 4 ...
Post a Comment
Read more

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

50 year old female

A 50 YEAR OLD FEMALE  A 50 year old female came to the OPD with   CHIEF COMPLAINTS-  Pain   Stiffness in several joints since three months HISTORY OF PRESENTING ILLNESS- Patient was apparently asymptomatic 10 years ago then she developed a dull aching type of pain and stiffness in her metacarpophalangeal joints in her right hand associated with limitation of movements at the joint . Then within 6 months of the onset of the disease, it has progressed to involve other joints of the right hand,left hand as well as wrist and elbow joint   Then within 4 years of onset she started feeling pain in the joints of feet and ankle   Since 3 months the pain  became unbearable limiting her activities . PAIN  was insidious in onset,slowly progressive,dull aching type of pain,non radiating,associated with swelling ,stiffness and limitation of movements in the involved joint.       STIFFNESS and PAIN was more in the first one hour of waking up ...
Post a Comment
Read more