1701006161 CASE PRESENTATION
LONG CASE:
- HCV - negative
- HBsAg - negative
* Troponin I - 22.5 ng/dl
* ABG :
8/06/2022:
- pH - 7.43
- pCO2 - 26.8 mmHg
- pO2 - 76.3 mmHg
- HCO3 - 17.6 mmol/L
- St.HCO3 - 20.4 mmol/L
- O2 saturation - 93%
- Total CO2 - 35.0 mmol/L
9/06/2022:
- pH - 7.43
- pCO2 - 26.8 mmHg
- pO2 - 76.3 mmHg
- HCO3 - 17.6 mmol/L
- St.HCO3 - 20.4 mmol/L
- O2 saturation - 94%
- Total CO2 - 35.0 mmol/L
* ECG -
8/06/2022
* Echo 2D -
* Xray -
PROVISIONAL DIAGNOSIS:
Heart failure with - dialated cardiomyopathy and atrial fibrillation.
TREATMENT:
8/06/2022:
* Inj. AUGMENTIN - 1.2gm\IV stat\BD
* Inj. THIAMINE - 200mg in 50ml normal saline IV stat\BD
9/06/2022:
* Inj. AUGMENTIN - 1.2gm\IV\BD
* Inj LASIX 40mg\IV\TID
* Inj. OPTINEURON - 1 ampoule in 100ml normal saline IV\OD
* Inj. PANTOP - 40mg IV\OD
* Inj. HYDROCORT 100mg IV\BD
* Tab AZITHROMYCIN 500mg PO\BD
* Neb with DUOLIN - 8th hourly
* Neb with BUDECORT - 8th hourly
10/06/2022:
* Inj. HYDROCORT 100mg IV\BD
* Inj. THIAMINE - 200mg in 50ml normal saline IV\BD
* Tab AZITHROMYCIN 500mg PO\BD
* Neb with DUOLIN - 18th hourly
* Neb with BUDECORT - 18th hourly
* Inj. OPTINEURON - 1 ampoule in 100ml normal saline IV\OD
* Tab. CORDARONE - 150mg IV\BD
* Tab. ECOSPRIN - 180mg OD
* Tab. CLOPITAB - 75mg OD.
* Inj. CLEXANE - 60mg SC.
11/06/2022:
* Inj. AUGMENTIN - 1.2gm\IV\BD
* Tab AZITHROMYCIN 500mg PO\BD
* Tab. CORDARONE - 150mg PO\BD
* Inj. CLEXANE - 60mg SC\OD
* Tab. ECOSPRIN - 150mg PO\OD
* Tab. CLOPITAB - 75mg PO\OD.
* Tab ATORVAS - 80mg PO
* Neb with IPPAVART - 12th hourly
* Neb with BUDECORT - 12th hourly
12/06/2022:
* Tab. AUGMENTIN - 65mg PO\BD
* Tab. AZITHROMYCIN - 500mg PO\BD
* Tab. CORDARONE - PO\BD
* Inj. CLEXANE - 60mg SC\OD
* Tab. ECOSPRIN - 150mg PO\OD
* Tab. CLOPITAB - 75mg PO\OD.
* Tab ATORVAS - 50mg PO\OD
* Inj. LASIX - 40mg\IV\TID
* Tab. DILTIAZAM - 30mg PO\BD
* Inj. THIAMINE - 20mg IV\TID
* Neb with BUDECORT - 12th hourly
SHORT CASE:
The patient was apparently asymptomatic 6 months ago when he developed jaundice and was treated at a private practitioner.
Later he developed abdominal distension about 7 days ago - insidious in onset, gradually progressive to the present size - associated with
- Pain in epigastric and right hypocondrium - colicky type.
- Fever - high grade, not associated with chills and rigor, decreased on medication, No night sweats.
- Not associated with Nausea, vomiting, loose stools
There was pedal edema
- Gradually progressive
- Pitting type
- Bilateral
- Below knees
- Increases during the day - maximum at evening.
- No local rise of temperature and tenderness
- Grade 2
- Not relived on rest
He also complained of shortness of breath since 4 days - MRC grade 4
- Insidious in onset
- Gradually progressive
- Agrevated on eating and lying down ; No relieving factors
- No PND
- No cough/sputum/hemoptysis
- No chest pain
- No wheezing
Patient is a known alcoholic since 20 years. Ascites increased after his last drink on 29th May, 2022.
Daily Routine :
Wakes up at 5am and goes to field.
Comes home at 8am and has rice for breakfast. Returns to work at 9am.
1pm - lunch
2-6 pm - work
6pm - home
8pm - dinner
Alcohol- 2 times a week, 180 ml.
PAST HISTORY:
No history of similar complaints in the past
Medical history- not a known case of DM, HTN, TB, Epilepsy, Asthma, CAD
Surgical history - not significant
PERSONAL HISTORY:
- Diet - mixed
- Appetite- reduced since 7 days
- Sleep - disturbed
- Bowel - regular
- Bladder - oliguria since 2 days, no burning micturition, feeling of incomplete voiding.
- Allergies- none
- Addictions - Beedi - 8-10/day since 20 years ;
- Alcohol - Toddy - 1 bottle, 2 times a week, since 20 years;
- Whiskey-180 ml, 2 times a week, since 5 years.
- Last alcohol intake - 29th May, 2022.
FAMILY HISTORY:
Not significant
GENERAL EXAMINATION:
Patient is conscious, coherent and co-operative.
Examined in a well lit room.
Moderately built and nourished
Icterus - present (sclera)
Pedal edema - present - bilateral pitting type, grade 2
No pallor, cyanosis, clubbing, lymphoedenopathy.
Vitals :
Temperature- febrile
Respiratory rate - 16cpm
Pulse rate - 101 bpm
BP - 120/80 mm Hg.
SYSTEMIC EXAMINATION:
*CVS : S1 S2 heard, no murmurs.
*Respiratory system : normal vesicular breath sounds heard.
*Abdominal examination:
INSPECTION :
Shape of abdomen- distended
- Umblicus - everted
- Movements of abdominal wall - moves with respiration
- Skin is smooth and shiny;
- No scars, sinuses, distended veins, striae.
PALPATION :
Local rise of temperature - present.
Tenderness present - epigastrium.
Tense abdomen
Guarding present
Rigidity absent
Fluid thrill positive
Tremors seen.
Liver not palpable
Spleen not palpable
Kidneys not palpable
Lymph nodes not palpable
PERCUSSION:
Liver span : not detectable
Fluid thrill: felt
AUSCULTATION:
Bowel sounds: heard in the right iliac region
*CNS EXAMINATION:
Conscious
Speech normal
No signs of meningeal irritation
Cranial nerves: normal
Sensory system: normal
Motor system: normal
Reflexes: Right. Left.
Biceps. ++. ++
Triceps. ++. ++
Supinator ++. ++
Knee. ++. ++
Ankle ++. ++
Gait: normal
INVESTIGATIONS:
*Serology:
HIV - negative
HCV - negative
HBsAg - negative
* ECG: Normal.
*Hemogram:
PROVISIONAL DIAGNOSIS:
Acute decompensated liver failure with ascites- secondary to alcohol consumption.
TREATMENT:
Inj. PAN 40mg IV OD
Inj. Lasix 40mg IV BD
Inj. Thiamine 1 amp in NS 100ml IV TID
tab. Spironolactone 50mg PO BD
Syp. Lactose 15ml PO HS
Abdominal girth charting - 4th hourly
Fluid restrictriction less than 1l per day
Salt restriction less than 2 gms per day
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