34 year old with cirrhosis

FEBRUARY 27, 2022

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 THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT 
 
CHEIF COMPLAINTS :-

C/O YELLOWISH DISCOLORATION  of eyes and urine since7-8 days
c/o abdominal distension since 7days

HISTORY OF ILLNESS:-

Hopi-pt was apparently asymptomatic 7 months back,then the first time he had yellowish discoloration of eyes he was admitted to a local hospital and was diagnosed with alcoholic liver disease and was advised to stop alcohol.

PERSONAL HISTORY:-

He is an electrician and a local fisherman 34 years old who is addicted to alcohol
2 months back his brother expired,out of agony he again started drinking excess alcohol 180-360 ml since 40 days.

patient developed progressive distension of abdomen associated with yellowish discoloration of eyes and urine.

h/o fever on and off since 1 week

h/o constipation since 2 days

no h/o melena,hematemesis,no sleep disturbances

Past h/o-not a known case of  DM,HTN

Treatment h/o-no known drug allergies

FAMILY HISTORY :-
no significant family history

Personal history:-
patient moderatly built and moderately nourished

bowel -constipation since 2 days

addictions-alcohol-whisky 180-360 ml daily

General examination:-
pt is concious , coherent and coperative

ictreus-present,pedal edema-present



no pallor/cyanosis/lymphadenopathy

vitals-
bp-80/50 mmhg
pr-80 bpm
rr-16 cpm
spo2-98


p/a-distended,non tender,free fluid-present,bowel sounds-present



Investigations-

USG

ECG


Diagnosis-Cirrhosis secondary to alcohol with portal hypertension with gross ascites

Treatment-
1.inj thiamine 1 amp in 100 ml ns iv/bd
2.inj pan 40 mg iv/od
3.in zofer 4 mg iv/od
4.tab lasix 20 mg po/bd
5.tab aldactone 50 mg po /od
6.bp/pr/temp monitoring 4th hourly

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