CHRONIC LIVER DISEASE (CLD) SECONDARY TO ALCOHOLISM
A 43 year old male laborer by occupation presented with chief complaints of pedal edema since 30 days, abdominal distension since 15 days.
HISTORY OF PRESENTING ILLNESS:
The patient was apparently asymptomatic 30 days back, had history of sudden onset of swelling in the bilateral lower limbs, insidious, gradually progressive bilaterally up to the knee, pitting type, tender since 30 days, abdominal distension-progressive since 15 days, and not associated with facial puffiness, fatigue.
No h/o of fever, pain abdomen, nausea, vomiting, SOB, palpitations.
HISTORY OF PAST ILLNESS:
No h/o of similar complaints in the past
K/C/O DM II since 5 years(on medication for 2 years, later stopped)
N/K/C/O Epilepsy, Hypertension, TB
PERSONAL HISTORY
Mixed diet
Appetite normal
Sleep adequate
Bowel and Bladder movements regular
Addiction- Consumption of liquor since 18 years (180 ml)
Tobacco chewing:1-2/day since 15 years
FAMILY HISTORY:
Not significant
DRUG HISTORY:
On medication for DM II since one month
No known allergies
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative
Moderately built and Moderately nourished
No Pallor
No Cyanosis
No Clubbing
No Icterus
No Generalized lymphadenopathy
Pedal edema-Bilateral, pitting type up to the knee
VITALS
Temperature: Afebrile
PR: 74 bpm
RR: 16 cpm
BP: 110/60 mm of Hg
SPO2: 98%
SYSTEMIC EXAMINATION:
CARDIOVASCULAR SYSTEM:
S1, S2 heard
No murmurs
RESPIRATORY SYSTEM:
BAE+
NVBS heard
CENTRAL NERVOUS SYSTEM:
Intact
No focal defect
No abnormality detected
ABDOMEN:
Distended abdomen
Scar is present in the centre
Umbilicus everted
Hernial orifices normal
Visible veins present
No visible pulsations
Palpation
Tenderness+
No local rise in temperature
Inspectory findings are confiirmed
No palpable mass
Liver, spleen not palpable
Free fluid present
Fluid thrills absent
Percussion:
Shifting dullness present
Auscultation:
Bowel sounds heard
INVESTIGATIONS:
24/07/2021
HEMOGRAM:
LIVER FUNCTION TEST:
SERUM ELECTROLYTES:
SERUM CREATININE:
ASCITIC FLUID PROTEIN SUGAR:
ASCITIC FLUID FOR LDH:
HIV 1/2 RAPID TEST:
ANTI HCV ANTIBODIES-RAPID:
HBsAg -RAPID:
26/07/2021
25/07/2021
No fresh complaints, stools passed
O/E, pt is c/c/c
afebrile
PR 74 bpm
BP 110/60 mm Hg
RR 16 cpm
SPO2 98% on room air
GRBS 151 mg/dl
CVS: S1 S2 heard
RS: NVBS +
P/A DISTENDED, FREE FLUID+, FLUID THRILL+
Rx:
FLUID RESTRICTION <1L/DAY
INJ THIAMINE 1AMP IN 100ML NS IV/BD
INJ OPTINEURON 1AMP IN 100ML NS IV/OD
T. LASILACTONE (40/100) PO/OD
T. RIFAXIMIN 550 MG PO/OD
SYP LACTULOSE 15 ML PO/OD TO PASS [STOOLS <= 2/DAY]
ABDOMEN GIRTH AND WEIGHT MONITORING -DAILY
BP/PR/TEMP/RR- 4TH HRLY
GRBS- 6TH HRLY
INFORM GRBS
INJ HAI S/C ACC TO SLIDING SCALE
8AM - 2PM - 8PM
26/07/2021
No fresh complaints, stools passed
Appetite improved
O/E, pt s c/c/c
Afebrile
PR
BP
RR
CVS: S1 S2 heard
CNS: No abnormality detected
RS: NVBS+
P/A: DISTENDED, FREE FLUID+, FLUID THRILLS ABSENT
Rx:
FLUID RESTRICTION<1L/ DAY
SALT RESTRICTION<2.4GR/ DAY
INJ THIAMINE 1 AMP IN 100 ML NS IV/TID
INJ OPTINEURON 1 AMP IN 100 ML NS IV/ OD
T. LASILACTONE(40/100) PO/OD
T. RIFAXIMIN 550 MG PO/BD
ABDOMINAL GIRTH MONITOR DAILY
WEIGHT MONITORING DAILY
BP/ PR/ TEMP/ Rx- 12 TH HRLY
GRBS- 6 TH HRLY
HAI S/C ACC TO SLIDING SCALE
8 AM - 3 PM - 8PM
T. LIVOGEN 150 MG PO/OD
I/O CHARTING
