60year old male with abdominal distension

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A 60 year old male came to the casualty with the chief complaints of distension of abdomen since 2-3 months, bilateral lower limb swelling since 1 month and dark stools since 4 days. 

Patient was apparently normal 11 years back following which he developed sudden onset of chest pain associated with sweating and diagnosed with ? CAD and had CAG + PTCA and was on regular follow up since then.
 4 months later he had persistent headache and neck pain for which he was taken to the hospital nearby where he was diagnosed with HTN and Diabetes and treated accordingly. 
3 months back patient noticed progressive abdominal distension associated with SOB grade 3 for which he consulted the local RMP and got treated but refused to get admitted in hospital as he had to attend his daughter’s marriage in the coming week. Exactly one day after his daughter’s wedding patient had a bout of vomiting with fresh blood as content.
On Tuesday patient came to KIMS - NKP Gastro OPD, endoscopy was done which reveals grade 2-3 esophageal varices then he was immediately referred to KIMS - KHL for banding. Patient got admitted in KHL and banding was done. 
X RAY shows right sided massive effusion for which ICD was placed, large volume paracentesis done, 3L ascitic fluid recovered. 
INJ. Albumin and ocreotide was given.

K/c/o DM and HTN 
K/c/o CAD S/P PTCA 
Personal history - Consumes mixed diet, appetite lost, regular bowel movements 
Smoking history of 5-6 years and stopped 6 months back 

No significant family history 

Patient is conscious, coherent and cooperative 
Pallor and edema + 
Bp 110/90 mmhg 
Pr 80bpm 
Rr 17cpm 
Spo2 95%@ room air 
Grbs 103 mg/dl

CVS - s1 s2 + 
No murmurs 
RS - bae + NVBS
CNS - no FND
P/A - soft, non tender and distended abdomen

On 26/11/2021
on 27/11/2021


Provisional Diagnosis- Chronic Liver Disease with Portal Hypertension 

Investigations - 

Pleural fluid (KHL) - no organism, AFB -, protein 1.4, sugar 131, Ada - 13, cytology - reactive effusion 
PT 20 s
INR 1.4 
APTT 37s 
HB 7.7 
TLC 5300
PLT 1.10 L 
Na 141
K 3
Cl 101 
S. Creat 0.9 
Urea 21

USG- 1. Altered echo texture with irregular surface of liver f/s/o chronic liver disease 
2. Cholelithiasis
3. Diffuse subcutaneous edema noted in the abdominal wall
On 26/11/2021
Treatment - 
1. TAB. LASIX 40 mg BD 
2. TAB ALDACTONE 50 mg OD
3. TAB PAN 40 mg PO OD 
4. FLUID AND SALT RESTRICTION
5. SYP. POTKLOR 10ml PO BD 
6. INJ. HAI S/C acc to grbs charting 
7. BP/PR/ TEMP CHARTING 4th HOURLY 
8. DAILY BODY WEIGHT AND ABDOMINAL GIRTH MONITORING 
9. GRBS MONITORING TID 
10. ICD CARE 
11. PROTEIN X POWDER 2 SCOOPS IN 100 ML MILK BD
Investigations on 28/11/2021
ECG
 INVESTIGATIONS ON 29/11/2021

X-RAY  ON 30/11/2021


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