CHRONIC LIVER DISEASE WITH PORTAL HYPERTENSION WITH HEPATOSPLENOMEGALY
"This is an online E log book 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 series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment"
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
Comments
Post a Comment