GENERAL MEDICINE E-LOG

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E-LOG was done under the guidance of Dr.Madhumitha 

CHIEF COMPLAINT: 

A 55 year old male, R/o nalgonda, came to the opd with chief complaints of 

• Abdominal pain and distention since 1 month
• Generalized weakness since 1 month
• B/L pedal edema since 1 month and 
• Yellowish discoloration of eyes since 1 month.

Date of admission: 7/7/21

HISTORY OF PRESENT ILLNESS: 

Patient was apparently asymptomatic 1 month back when he developed diffuse abdominal pain and abdominal distention, 

B/L pitting type of pedal edema extending upto knees,

Yellowish discoloration of eyes and urine,

And burning micturition. 

No h/o fever, vomitings, hematemesis, decreased urine output, chest pain, sob, palpitations. 

Patient gives h/o going to some local hospital for the presenting complaints where he got treated but his symptoms didn't get subsided. Then he took herbal medicine also with which his symptoms didn't subside. Now he came to our hospital.

HISTORY OF PAST ILLNESS:

He is a k/c/o Hypertension. 

PERSONAL HISTORY:

He is chronic alcoholic since 30 years. His amount of alcohol consumption has been increased from 360ml/day to 720ml/day since last 5 years.

GENERAL EXAMINATION: 

Patient is conscious.

Icterus is present.

B/L Pedal edema is present.

Absence of pallor, cyanosis, clubbing, lymphadenopathy.

VITALS:

1. Temperature = 98.6F
2. Pulse rate = 82 beats per minute 
3. Respiratory rate= 18 cycles per minute
4. BP= 70/40mmHg.
5. SpO2 = 98% @Room air.

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

• S1,S2 heard, no murmurs. 

RESPIRATORY SYSTEM:-

• Trachea is central,
• Vesicular breath sounds heard,
• Crepts in Left ISA, IAA, Interscapular areas.

EXAMINATION OF ABDOMEN:

• Abdomen is distended.
• No tenderness.

                      

ASCITIC FLUID TAP 

CENTRAL NERVOUS SYSTEM:

• No abnormality detected.

PROVISIONAL DIAGNOSIS:

CHRONIC LIVER DISEASE SECONDARY TO ALCOHOL

ASCITIES +

ANAL FISSURE GRADE-2 HEMORRHOIDS

INVESTIGATIONS:

 Investigations on 7/7/21:

                                        

CHEST X-RAY

Biochemical investigations:

                                 

BLOOD SUGAR-RANDOM 

LIVER FUNCTION TESTS(LFT)

RENAL FUNCTION TESTS(RFT)

Pathological investigations:

                                  

APTT

HEMOGRAM

PROTHROMBIN TIME

ULTRASOUND REPORT

2D ECHO REPORT

TREATMENT:

Treatment on 9/7/21:

1.     Inj. Vit-K 10mg×IV×OD

   2.      Tab UDILIU 300mg×PO×OD

   3.      Tab RIFAGUT 550mg×PO×OD

   4.      Tab PAN 40mg×PO×OD

   5.      Syp HERPAMERZ 10ml×TID

   6.      2 egg whites/day

   7.      BP/PR/RR/Temp/SPo2 monitoring

   8.      Syp LACTULOSE 20ml PO/HS

   9.      Abdominal girth measurement

   10.   Tab BENFOMET PLUS ×40mg×PO×OD

   11.   Tab ALDACTONE 25mg×PO×OD

     
Unfortunately, the patient went LAMA(Leaving Against Medical Advice) on 10/7/21. So, we don't have any further information on this patient.

           

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