General Medicine - 5
July 20, 2022
Hepatitis C test: negative
A 49 YEAR OLD MALE CAME WITH ABDOMINAL DISTENSION AND PEDAL EDEMA.
Hi, I am Dussa Sri Snehitha, 3rd sem medical student.This is an online elog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio.
CASE SHEET:
Chief complaints:
A 49 year old male, driver by occupation came to causality with chief complaints of:
- Abdominal distention since 10 days
- pedal edema since 10 days
HISTORY OF PRESENT ILLNESS:
The patient was apparently asymptomatic 20 years back. At age of 10, he developed seizures, which subsided itself without any medication.
10 years back, patient has scaly lesions on hands and legs for which he was diagnosed as psoriasis. Since then he was on regular medication.
A year back, the patient has yellowish discoloration of sclera for which he used herbal medicine for 6 days. Again after 3 months, he had similar case of yellowish discoloration of sclera for which he used herbal medicine for 7 days.
He had yellowish discoloration for 20 days and distention of abdomen for 10 days and pedal edema for 10 days.
ASSOCIATED DISEASES:
No significant diseases.
PAST HISTORY:
The patient was a known case of psoriasis 20 years back.
PERSONAL HISTORY:
Diet: Mixed
Bowel : constipation since 20 days
Micturition: Burning micturition
Appetite: Decreased
Habits: Regular alcoholic since 7 years
No history of allergy, asthma, tuberculosis, coronary artery disease.
FAMILY HISTORY:
No significant family history.
DRUG HISTORY:
No significant drug history
GENERAL EXAMINATION:
No pallor
No cyanosis
No clubbing
No lymphadenopathy
No malnutrition
No dehydration
Icterus present
Pedal edema
VITALS:
Temperature: 98.4 F
Pulse: 89 beats per minute
Respiratory rate: 16 cycles per minute
Blood pressure: 120/70 mm of Hg
SPO2: 99%
SYSTEMIC EXAMINATION:
Cardiovascular system:
No thrills
No murumurs
Cardiac sounds: S1, S2 heard
Respiratory system:
No dyspnea
No wheezing
Breath sounds heard: vesicular
Abdomen:
Shape: distended
No tenderness
No palpable mass
Non palpable liver
Non palpable spleen
No bruits
Bowel sounds: heard
Central Nervous System:
Conscious
Speech: normal
INVESTIGATIONS:
Biochemical investigations:
LFT:
Hepatitis B test: negative
ECG:
PROVISIONAL DIAGNOSIS:
Chronic liver disease.
TODAY'S UPDATE: JULY 21, 2022
The patient was given the following medication:
INJ: LASIX 40mg ( if spb greater or equal to 110 mm of Hg)
TAB: SPIRINOLACTONE 50mg po/od
TAB: UDILIV 300mg po/bd
TAB: RIFAGUT 550mg po/bd
SYRUP: LACTULOSE 30ml po/td
TODAY'S UPDATE: JULY 22, 2022
The patient was on same medication in addition to:
MOISTUREX SOFT LOTION - 2 weeks
BENZAC AC GEL -od (face)- night time- 2 weeks
After taking consent, USG guides ascitic tap done and 20ml ascitic fluid aspirated.
TODAY'S UPDATE: JULY 23, 2022
TAB: LASIX 40mg po/td
TAB: SPIRINOLACTONE 100mg po/od
TAB: UDILIV 300mg po/bd
TAB: RIFAGUT 550mg po/bd
SYRUP: LACTULOSE 30ml po/td
TODAY'S UPDATE: JULY 24, 2022
TAB: LASIX 40mg po/td
TAB: SPIRINOLACTONE 100mg po/od
TAB: UDILIV 300mg po/bd
TAB: RIFAGUT 550mg po/bd
SYRUP: LACTULOSE 30ml po/td
INJ: VITAMIN K (amp) 100 ml iv/od
PROTIENEX POWDER IN 100ml of milk po/td
TODAY'S UPDATE: JULY 26, 2022
TAB: LASIX 40mg po/td
TAB: SPIRINOLACTONE 100mg po/od
TAB: UDILIV 300mg po/bd
TAB: RIFAGUT 550mg po/bd
SYRUP: LACTULOSE 30ml po/td
INJ: VITAMIN K (amp) 100 ml iv/od
PROTIENEX POWDER IN 100ml of milk po/td
TODAY'S UPDATE: JULY 27, 2022
TAB: LASIX 40mg po/td
TAB: SPIRINOLACTONE 100mg po/od
TAB: UDILIV 300mg po/bd
TAB: RIFAGUT 550mg po/bd
SYRUP: LACTULOSE 30ml po/td
INJ: VITAMIN K (amp) 100 ml iv/od
PROTIENEX POWDER IN 100ml of milk po/td
TODAY'S UPDATE: JULY 28, 2022
TAB: LASIX 40mg po/td
TAB: SPIRINOLACTONE 100mg po/od
TAB: UDILIV 300mg po/bd
TAB: RIFAGUT 550mg po/bd
SYRUP: LACTULOSE 30ml po/td
INJ: VITAMIN K (amp) 100 ml iv/od
PROTIENEX POWDER IN 100ml of milk po/td
TAB: PANTOP 40mg po/od
BENZAC- AC GEL - od (face) 2 weeks
MOISTUREX SOFT LOTION - (body) 2 weeks
TODAY'S UPDATE: JULY 29, 2022
TAB: LASIX 40mg po/td
TAB: SPIRINOLACTONE 100mg po/od
TAB: UDILIV 300mg po/bd
TAB: RIFAGUT 550mg po/bd
SYRUP: LACTULOSE 30ml po/td
INJ: VITAMIN K (amp) 100 ml iv/od
PROTIENEX POWDER IN 100ml of milk po/td
TAB: PANTOP 40mg po/od
BENZAC- AC GEL - od (face) 2 weeks
MOISTUREX SOFT LOTION - (body) 2 weeks
E/D: LUBREX 5 times/day
ISSUE OF FFP:
Blood group: O+ve
4 units of RBCRBC
TODAY'S UPDATE: JULY 30, 2022
TAB: LASIX 40mg po/td
TAB: SPIRINOLACTONE 100mg po/od
TAB: UDILIV 300mg po/bd
TAB: RIFAGUT 550mg po/bd
SYRUP: LACTULOSE 30ml po/td
INJ: VITAMIN K (amp) 100 ml iv/od
PROTIENEX POWDER IN 100ml of milk po/td
TAB: PANTOP 40mg po/od
BENZAC- AC GEL - od (face) 2 weeks
MOISTUREX SOFT LOTION - (body) 2 weeks
TAB: VIBOLIV 500mg po/bd
TAB: MAXILIV 500mg po/bd
TAB: ANTIOXID po/od
E/D: LUBREX 5 times/day
TAB: PREDNISOLONE 20mg po/od
TODAY'S UPDATE: AUGUST 01, 2022
The patient was on same medication.
He was recommended to gastroenterology
Ascitic fluid shows low protein and high SAAG.
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