CHRONIC LIVER DISEASE WITH PORTAL HYPERTENSION WITH HEPATOSPLENOMEGALY
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A 42yr old Male ,who is milk vendor came to casualty with
C/O• Abdominal pain since 10 days
•Yellowish discoloration of sclera and urine since 1 week
•Vomitings 6-7 episodes/day
•Loose stools 6-7 episodes/day
•Giddiness since 2 days
HISTORY OF PRESENT ILLNESS:-
Patient was apparently asymptomatic 10 days ago,then he developed abdominal pain since 10 days which is insidious in onset, dragging type.
•Yellowish discoloration of sclera and urine since 1 week
•Vomitings 6-7 episodes/day—non-projectile,non-bilious
•Loose stools 6-7 episodes/day ,Non blood stained
•Sleeplessness and irrelevant talks since 1 week ( according to patient attenders)
•Giddiness since 2 days
From 5 years, he is having disputes with his wife which is reason for increased Alcohol consumption
3 Years ago,he attempted suicide (OP poisoning-250 ml )after he separated from his wife .H/O disoriented to place,time,person at that time
From 7 months,he made a new friend who also lives alone. Started tobacco chewing and increased Alcohol consumption.
PAST HISTORY:
Consumption of alcohol since 15years —90ml /day
Last binge of alcohol 15 days ago
PERSONAL HISTORY:-
Diet - mixed
Appetite- Normal
Sleep- inadequate
Bowel and bladder movements- yellowish discoloration of urine and stools
Addictions-
•Alcohol consumption since 15 years- Daily 180ml
•Tobacco chewing- occasionally
Lifestyle-
He wakes up 8AM,then he goes to sell the collected milk from the nearby village (by his brother) upto 11 AM.From then ,he takes Alcohol along with his friends , returns back to home by 3PM.
At 3PM, he eats some food and sleep till night.
Wakes up night @9 PM,eats some food and sleep again
GENERAL EXAMINATION:
Pt is conscious,coherent,cooperative
Bp-110/80 mmHg
Pr-99bpm
Temp -98.5°F
SpO2- 99%@RA
GRBS -154mg/dl @admission
Icterus present in both eyes
No Pallor,cyanosis,lymphadenopathy ,odema, clubbing
CVS : S1 S2 +, Apex beat : 5th ICS mid clavicular line.
RS : BAE +, NVBS
CNS : NAD
Apraxia chart:
Day1
Day 2
P/A : Soft, no tenderness, Bowel sounds +
Liver span -17 cms(increased)
Spleen palpable
Spider nevi present
https://youtu.be/-RBzLslnF_4
PROVISIONAL DIAGNOSIS:-
•CHRONIC LIVER DISEASE WITH PORTAL HYPERTENSION WITH HEPATOSPLENOMEGALY
? HEPATIC ENCEPHALOPATHY
•ALCOHOL DEPENDENCE SYNDROME
INVESTIGATIONS:-
USG:
SOAP NOTES Day 2
S- No fresh complaints
O- Patient is consious, non co-herent,non co-operative, irrelevant talks
Icterus++
No pallor,odema, cyanosis, clubbing, lymphadenopathy.
VITALS :
Temperature - 98.4F
Pulse rate - 84BPM, REGULAR, NORMAL VOLUME
BP -@6AM-180/120 mm of hg —Nicardia 5mg,Inj.Lasix 20mg given
@8AM110/80MM OF HG
SPo2 - 98%@RA
GRBS:
On 18/4/22
@8AM :109mg/dl
SYSTEMIC/ EXAMINATION -
P/A : Non distended, soft,non-tender, liver span of 17cms,spleen palpable , No guarding or rigidity.
CVS : S1 S2 heard , no murmurs
RS : BAE +, NVBS
CNS : Tremors present
A -CHRONIC LIVER DISEASE WITH PORTAL HYPERTENSION WITH HEPATOSPLENOMEGALY ? HEPATIC ENCEPHALOPATHY
•ALCOHOL DEPENDENCE SYNDROME
P -Psychiatric evaluation i/v/o Alcohol dependence syndrome
SOAP NOTES Day 3
S- No fresh complaints
Decreased Abdominal pain
No yellowish discoloration of urine and stools
Passed stools once in the morning
O- Patient is consious, co-herent, co-operative,, oriented to place , time,person,no visual hallucinations (irrelevant talks , disoriented to place ,time ,person upto 8 PM on 18/4/22)
Icterus++
No pallor,odema, cyanosis, clubbing, lymphadenopathy.
VITALS :
Temperature - 98.4F
Pulse rate - 84BPM, REGULAR, NORMAL VOLUME
BP -
@8AM-90/60MM OF HG
SPo2 - 98%@RA
GRBS:
On 18/4/22
@8AM :109mg/dl
2AM-92MG/DL
8 PM-108MG/DL
ON 19/4/22@8AM-97 mg/dl
SYSTEMIC/ EXAMINATION -
P/A : Non distended, soft,non-tender, liver span of 17cms,spleen palpable , No guarding or rigidity.
CVS : S1 S2 heard , no murmurs
RS : BAE +, NVBS
CNS : Tremors present
A -CHRONIC LIVER DISEASE WITH PORTAL HYPERTENSION WITH HEPATOSPLENOMEGALY
? HEPATIC ENCEPHALOPATHY
•ALCOHOL DEPENDENCE SYNDROME
P -1.gastroenterology opinion
2.Inj.Loraz 2mg IM /Sos
3.Syp.Lactulose 10ml/PO/TID
SOAP NOTES Day 4
S- No fresh complaints
•Decreased Abdominal pain
O- Patient is consious, co-herent, co-operative,, oriented to place , time,person,no visual hallucinations
Icterus++
No pallor,odema, cyanosis, clubbing, lymphadenopathy.
VITALS :
Temperature - 98.4F
Pulse rate - 84BPM, REGULAR, NORMAL VOLUME
BP -
@8AM-130/70MM OF HG
SPo2 - 98%@RA
GRBS:
On 18/4/22
@8AM :97mg/dl
2AM-92MG/DL
8 PM-127MG/DL
ON 19/4/22@8AM-195 mg/dl
SYSTEMIC/ EXAMINATION -
P/A : Non distended, soft,non-tender, liver span of 17cms,spleen palpable , No guarding or rigidity.
CVS : S1 S2 heard , no murmurs
RS : BAE +, NVBS
CNS : NAD
A -CHRONIC LIVER DISEASE WITH PORTAL HYPERTENSION WITH HEPATOSPLENOMEGALY
? HEPATIC ENCEPHALOPATHY
•ALCOHOL DEPENDENCE SYNDROME
SOAP NOTES Day 5
S- No fresh complaints
O- Patient is consious, co-herent, co-operative,, oriented to place , time,person,no visual hallucinations
Icterus++
No pallor,odema, cyanosis, clubbing, lymphadenopathy.
VITALS :
Temperature - 98.4F
Pulse rate - 84BPM, REGULAR, NORMAL VOLUME
BP -
@8AM-120/70MM OF HG
SPo2 - 98%@RA
GRBS:
ON 22/4/22@8AM-195 mg/dl
SYSTEMIC/ EXAMINATION -
P/A : Non distended, soft,non-tender, liver span of 17cms,spleen palpable , No guarding or rigidity.
CVS : S1 S2 heard , no murmurs
RS : BAE +, NVBS
CNS : NAD
A -CHRONIC LIVER DISEASE WITH PORTAL HYPERTENSION WITH HEPATOSPLENOMEGALY
? HEPATIC ENCEPHALOPATHY
SOAP NOTES Day 6
S- No fresh complaints
O- Patient is consious, co-herent, co-operative,, oriented to place , time,person,no visual hallucinations Icterus++
No pallor,odema, cyanosis, clubbing, lymphadenopathy.
VITALS :
Temperature - 98.4F
Pulse rate - 84BPM, REGULAR, NORMAL VOLUME
BP -
@8AM-120/70MM OF HG
SPo2 - 98%@RA
GRBS:
ON 23/4/22@8AM-97mg/dl
SYSTEMIC/ EXAMINATION -
P/A : Non distended, soft,non-tender, liver span of 17cms,spleen palpable , No guarding or rigidity.
CVS : S1 S2 heard , no murmurs
RS : BAE +, NVBS
CNS : NAD
A -CHRONIC LIVER DISEASE WITH PORTAL HYPERTENSION WITH HEPATOSPLENOMEGALY
? HEPATIC ENCEPHALOPATHY
•ALCOHOL DEPENDENCE SYNDROME
SOAP NOTES Day 7
S- Loose stools since yesterday night
O- Patient is consious, co-herent, co-operative,, oriented to place , time,person,no visual hallucinations Icterus++
No pallor,odema, cyanosis, clubbing, lymphadenopathy.
Passed stools once every hrly since yesterday night
VITALS :
Temperature - 98.4F
Pulse rate - 78BPM, REGULAR, NORMAL VOLUME
BP -
@8AM-120/70MM OF HG
SPo2 - 98%@RA
SYSTEMIC/ EXAMINATION -
P/A : Non distended, soft,non-tender, liver span of 17cms,spleen palpable , No guarding or rigidity.
CVS : S1 S2 heard , no murmurs
RS : BAE +, NVBS
CNS : NAD
A -CHRONIC LIVER DISEASE WITH PORTAL HYPERTENSION WITH HEPATOSPLENOMEGALY
? HEPATIC ENCEPHALOPATHY
•ALCOHOL DEPENDENCE SYNDROME
SOAP NOTES Day 8
S- No active complaints
O- Patient is consious, co-herent, co-operative,, oriented to place , time,person,no visual hallucinations
Icterus++
No pallor,odema, cyanosis, clubbing, lymphadenopathy.
VITALS :
Temperature - 98.4F
Pulse rate - 86BPM, REGULAR, NORMAL VOLUME
BP -
@8AM-120/90MM OF HG
SPo2 - 98%@RA
SYSTEMIC/ EXAMINATION -
P/A : Non distended, soft,non-tender, liver span of 17cms,spleen palpable , No guarding or rigidity.
CVS : S1 S2 heard , no murmurs
RS : BAE +, NVBS
CNS : NAD
A -CHRONIC LIVER DISEASE WITH PORTAL HYPERTENSION WITH HEPATOSPLENOMEGALY
? HEPATIC ENCEPHALOPATHY
•ALCOHOL DEPENDENCE SYNDROME
SOAP NOTES Day 9
S- No active complaints
O- Patient is consious, co-herent, co-operative,, oriented to place , time,person,no visual hallucinations
Icterus++
No pallor,odema, cyanosis, clubbing, lymphadenopathy.
VITALS :
Temperature - 98.4F
Pulse rate - 86BPM, REGULAR, NORMAL VOLUME
BP -
@8AM-130/80MM OF HG
SPo2 - 98%@RA
SYSTEMIC/ EXAMINATION -
P/A : Non distended, soft,non-tender, liver span of 17cms,spleen palpable , No guarding or rigidity.
CVS : S1 S2 heard , no murmurs
RS : BAE +, NVBS
CNS : NAD
A -CHRONIC LIVER DISEASE WITH PORTAL HYPERTENSION WITH HEPATOSPLENOMEGALY
? HEPATIC ENCEPHALOPATHY
•ALCOHOL DEPENDENCE SYNDROME
SOAP NOTES Day 10
S- No active complaints
O- Patient is consious, co-herent, co-operative,, oriented to place , time,person,no visual hallucinations
Icterus++
No pallor,odema, cyanosis, clubbing, lymphadenopathy.
Passed stools 8 times from yesterday morning
VITALS :
Temperature - 98.4F
Pulse rate - 86BPM, REGULAR, NORMAL VOLUME
BP -
@8AM-110/60MM OF HG
SPo2 - 98%@RA
SYSTEMIC/ EXAMINATION -
P/A : Non distended, soft,non-tender, liver span of 17cms,spleen palpable , No guarding or rigidity.
CVS : S1 S2 heard , no murmurs
RS : BAE +, NVBS
CNS : NAD
A -CHRONIC LIVER DISEASE WITH PORTAL HYPERTENSION WITH HEPATOSPLENOMEGALY
? HEPATIC ENCEPHALOPATHY
•ALCOHOL DEPENDENCE SYNDROME
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