54 YEAR OLD MALE PATIENT WITH DISTENTION OF ABDOMEN, JAUNDICE, BURNING MICTURITION SINCE 15 DAYS

 This is an online E Logbook 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 a series of inputs from an available global online community of experts to solve those patients' 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 in the comment box are welcome.

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A 54 YEAR OLD MALE  PATIENT CAME WITH COMPLAINTS OF 

1. DISTENSION OF ABDOMEN SINCE 15 DAYS

2. H/O JAUNDICE SINCE 15 DAYS

3.BURNING MICTURITION SINCE 15 DAYS

NO H/O FEVER,SOB,PEDAL EDEMA

HOPI: 

PATIENT WAS APPARENTLY ASYMPTOMATIC 5 MONTHS BACK, ON JAN 2021 PATIENT WAS OPERATED FOR GALL STONES.POST OP NO COMPLICATIONS AND WAS NORMAL . PATIENT DEVELOPED JAUNDICE ( YELLOWISH DISCOLOURATION OF SCLERA AND SKIN ) 15 DAYS BACK AND WAS TAKEN TO HOSPITAL AND GOT EVALUATED AND TREATED

PT IS A K/C/O CHRONIC LIVER DISEASE

K/C/O HTN

NOT A K/C/O DM, ASTHMA, EPILEPSY

K/C/O CLD, HTN

VITALS:

TEMP: 98.4 F

PR: 78/MIN

RR: 23/MIN

BP: 110/70 MMHG

NO PALLOR/CYANOSIS/ICTERUS/CLUBBING/OEDEMA

INVESTIGATIONS:


Ascitic tap :

21/04/2021 2.5lit done outside

25/12/2021: 1.5 lit done outside 

3/01/2022 : 1.5lit done here







DIAGNOSIS:

DECOMPENSATED CHRONIC LIVER DISEASE WITH GROSS ASCITES AND OESOPHAGEAL VARICES


TREATMENT GIVEN:


1) UNDER ASEPTIC CONDITIONS , ASCITIC TAP DONE AND 1.5 L WAS DRAINED


2) TAB.UDILIV 300MG/PO/BD


2)TAB.ALDACTONE 25MG/PO/OD


3)TAB.LASIX 20MG/PO/BD


4)SYP.LACTULOSE 10ML/PO/BD

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