50 yrs old male k/c/o HbsAg +ve with cirrhosis

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 box is welcome.

Team:

Interns-

M Supriya

Mohitha

K Sowmya

Sanjay

Amrutha


Dr.Druga Krishna PGY1

Dr.Ajith Kumar PGY2

Dr.Laxma Reddy PGY3

Dr.Manasa PGY3

Dr.Vijaya Lakshmi (Ast.Prof.)

A 50 year old male came with c/o distention of abdomen since 7 months,B/L pedal edema since 7 months, 

pt was apparently asymptomatic 7 months back then he developed  low grade fever with yellowish discolouration of eyes followed by pedal edema  which is gradually progressive and pitting type -no aggrevating and relieving factors,then he developed abdomenal distenstion which was insidious onset and gradually progressive along with H/o decreased urine output  then pt went to the local Hospital and started on conservative  management then pt symptoms  were relieved then pt had repeated follow up to the local Hospital..in the month of November  pt was diagnosed with Hbsag+ve ..and no where ascitic tap was done or attempted .previous report form november showed his platelet count was 65,000
Hb 11.2%. pt had on and off symptoms ...His aggravating  factors are Non veg food ,taking toddy ..and Relieving factors are Vegeterian diet and Medication usage.
past history 
previous reports 
k/c/o HbsAg since 3month 
Not a k/c/o DM ,HTN,TB,Asthma ,epilepsy
personal history 
Addictions- alcoholic since 20 yrs of age  takes 90ml daily along with1 glass  saara occasionally 
pt had h/o death of his wife 3 yrs back from then his alcohol intake was increased  from quarter to Half and toddy intake was also increased 
O/E
Patient is conscious coherent coperative 
moderately built
No signs of Icterus, cynosis, clubbing, lymphedenopathy, kilonycia 


Vitals
Bp -110/70
PR -87bpm
RR - 22 cpm
Spo2 98@room air

Systemic examination
Cvs -s1s2 +
Rs -BAE +

P/A -
-inspection-
shape -distented ,
umbalicus-central and partially everted ,
stirae present above the umbilicus, 
abdominal movements present on respiration,
no pulsatation, 
engorged veins are present
no scars and sinuses

-palpations-
no local rises of temperature,non tender,soft , non tender ,no organomegaly,
hernial orifices normal,
-percussion-
dull node on percussion is felt in epigastric region and flanks 


shift in dullness present 


fluid thrill present 


-Auscultation-
Bowel sounds +
CNS -normal 
Investigations 

Treatment-
on the day of admission 
1TAB SPIRONOLACTONE 50 MG/OD
2.TAB LASIX 40 MG/PO/TID
DAY 1
1TAB SPIRONOLACTONE 50 MG/OD
2.TAB LASIX 40 MG/PO/TID
DAY 2
1TAB SPIRONOLACTONE 50 MG/OD
2.TAB LASIX 40 MG/PO/TID
3.INJ VIT K 10 MG/IV/STAT

Provisional diagnosis-
k/c/o HbSAg +ve with cirrhosis 

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