65M with Abdominal distension

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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 series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 


This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome."

A 65yr old male patient, water plant supervisor by occupation came to casualty with 
Sob since 7 days
Abdominal distension since 15 days
Pedal edema since 6 months, aggrevated since 7 days. 
6 episodes of loose stools since 1 day

History of presenting illness

patient was apparently asymptomatic 6 months back, then he developed pedal edema (pitting type) which was relieved on elevation. 

Patient then developed shortness of breath ( on exertion, with orthopnea) since 1 month. Patient then developed abdominal distension since 15 days. 

History of Past illness 

H/o similar complaints in the past ascitic tap done 6 months back. 

K/c/o HTN since 1.5 years, on medication Amlodipine 5 mg 

K/c/o DM 2 since 3 years, on Glimperide 2 mg + Metformin 100 mg 
(Did not use Medication for a year )

H/o  CVA 10 years back 
Rt. U/L, L/L weakness

N/k/c/o  TB/ Asthma 


Personal History

Mixed diet 
Loss of appetite
Sleep disturbance
Normal bowel and bladder movements since medication given for Loose stools
Addictions: 
Alcohol consumption since 20 years 
Cigarette smoker since 20 years 

Family history
No relevant family history

O/E:
Temp- afebrile to touch   
BP-110/80mmhg
Pr-102/min                             
Spo2-97% on RA
Rr-18/min      
GRBS - 126 mg%

No- pallor, icterus, cyanosis, lymphadenopathy
B/l-pedal edema present 

Cvs-S1S2 heard, 
RS- BAE+, NVBS , mild expiratory ronchi, wheeze + 
P/A: distended, soft, non tender
CNS: NAD 


Investigations

ECG 

Ultrasound
Investigations Chart 

Differential Diagnosis: 

Chronic Liver ds. with Portal hypertension 2° to alcohol with gross ascites k/c/o HTN DM2 , H/o past CVA

Treatment: 

Day 1 

Tab. RIFAGUT 550mg / PO/ OD 
Tab. HEPAMAR 500mg / PO/ OD 
Syp. LACTULOSE 15mg / PO / TID 
Inj. HAF s/c acc. to GRBS 
GRBS monitoring 6th hourly
Syp. POTCHLOR 10ml in 1 glass of water PO/ TID

Day 2 

Inj. VITAMIN K 20 mg added in 50 ml NS/ IV / OD
Inj. THIAMINE 1amp in 100ml in NS / IV / BD
Tab. ALDACTONE 50mg/ PO / OD 
Tab. RIFAGUT 550mg / PO/ OD 
Tab. HEPAMAR 500mg / PO/ OD 
 Syp. LACTULOSE 15mg / PO / TID 
I Lasix 40mg/IV/ BD
Syp. POTCHLOR 10ml in 1 glass of water PO/ TID

Day 3

Inj. VITAMIN K 20 mg added in 50 ml NS/ IV / OD
Inj. THIAMINE 1amp in 100ml in NS / IV / BD
Tab. ALDACTONE 50mg/ PO / OD 
Tab. RIFAGUT 550mg / PO/ OD 
Tab. HEPAMAR 500mg / PO/ OD 
 Syp. LACTULOSE 15mg / PO / TID 
I Lasix 40mg/IV/ BD
Syp. POTCHLOR 10ml in 1 glass of water PO/ TID
Inj. CEFTRIAXONE 1mg / IV / BD 

Day 4 
Inj. VITAMIN K 20 mg added in 50 ml NS/ IV / OD
Inj. THIAMINE 1amp in 100ml in NS / IV / BD
Tab. ALDACTONE 50mg/ PO / OD 
Tab. RIFAGUT 550mg / PO/ OD 
Tab. HEPAMAR 500mg / PO/ OD 
 Syp. LACTULOSE 15mg / PO / TID 
I Lasix 40mg/IV/ BD
Syp. POTCHLOR 10ml in 1 glass of water PO/ TID
Inj. CEFTRIAXONE 1mg / IV / BD 

Day 5 
Inj. VITAMIN K 20 mg added in 50 ml NS/ IV / OD
Inj. THIAMINE 1amp in 100ml in NS / IV / BD
Tab. ALDACTONE 50mg/ PO / OD 
Tab. RIFAGUT 550mg / PO/ OD 
Tab. HEPAMAR 500mg / PO/ OD 
 Syp. LACTULOSE 15mg / PO / TID 
I Lasix 40mg/IV/ BD
Syp. POTCHLOR 10ml in 1 glass of water PO/ TID
Inj. CEFTRIAXONE 1mg / IV / BD 

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