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