70 year old with decompensated liver disease with portal hypertension with thrombocytopenia , hepatic encephalopathy ( resolved ) , ? spontaneous bacterial peritonitis .

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A 70 year old male came with 

c/o fever since 4 days

c/o pain abdomen since 4days 

C/o pedal edema since 3 days

C/o yellowish discoloration since 4days 

C/o fever since 4 days associated with chills and rigor,low grade ,on and off,lasted for 1 day,relieved on medication,c/o 1 episode of shivering 4 days back for t minutes 

No h/ o loc, uprolling of eyes ,frothing ,tongue bite 

C/o pain abdomen since 4days associated with distension since 4days 

No h/o vomintings loose stools decresed urine output ,sob ,chest pain, palpitataions

C/o buring mictuaration 4days back associated with loss of appetite 

C/o pedal edema since 4days 

C/o yellowish discoloration of eyes ,urine since 4days 

No h/o change in stool color ,pruritis 

No h/o any bleeding (hemoptysis,melaena bleeding gums) 

Alchoholic since 4p years daily 90 ml 

No h/o Smoking 

Outside reports 

Cue - albumin - nil 

          Pus cells -4 -5 

           Bile salts, bile pigments +

Lft 

Tb-6.7 , Db -3.8 ,Ib - 2.9 

CRP + 

RBS -132

haemogram 

Hb -12.4 , tlc - 14800 plt - 72000

Past h/o 

Similar complaints 8 years back diagnosed with alcoholic liver disease,ascitic tap was done ( no records available) 

No h/o DM,TB ,HTN ,ASTHMA ,EPILEPSY 

 

G/E : pt is c/c/c

Temp -99 F

PR 111 bpm 

BP - 120 / 70 mmhg 

RR - 24 cpm 

GRBS-108 mg/dl  

 

Cvs - S1S2 heard ,no murmers 

Resp - B/ l air entry present 

            NVBS 

            creps heard on left IAA

P/A 

      Soft ,tenderness present in epigastrium and right hypochondrium 

    Abdomen distended in all quadrants 

    Bowel sounds present

Investigations :

Serum amylase : 30 IU/L

Lft :TB - 9.02

DB - 7.21

AST -95

ALP - 538

Tp - 4.3

Albumin - 2.0

RFT 

Urea - 88

Uric acid - 7.4

Sodium- 132

PROTHROMBIN TIME - 20 SEC

INR - 1.4

APTT - 42 secs

Asicitic fluid ADA - 12 IU/l

Treatment : 

Salt restriction diet less than 2.5g/ day

Fluid restriction less than 1.5/day

3 eggs white 

O2 inhalation to maintain spo2

Protein powder 2 tsp in 100 ml po/BD

Inj thiamine 100mg in 100ml NS / IV/ TID

Inj optineuron 1amp in 100ml NS / IV / OD

Inj augmentin 1.2g IV / BD

Inj pantop 40mg IV / OD

Inj zofer 4mg IV / BD

BP /pr / spo2 charting 2nd hourly

Strict I/o charting

Grbs charting 6th hourly

Temperature charting 4th hourly

Tab udiliv 300mg PO / BD

Tab aldactone 25mg BD

Syp. Lactulose 15mg PO/BD

Daily abdominal girth and weight charting

Inj vit k 10mg IV 

Tab rifaximin 550mg PO/BD

Day 2 :

No fever spikes , pt passed stools yesterday , did not pass today

O/e : pt is c/c , icterus + 

Abd. Girth : 85cms

Wt : 60kgs

I/o : 1300/1000

Grbs : 71 

Pr : 110bpm

BP : 130/80mmhg

Asterixis : + , fine tremors : +

CVS : S1 S2 +

RS : BAE + , fine crepts + in RT and LtIAA

CNS : no FND

Investigations

APTT : 34 secs

PT  : 17 secs

INR : 1.2 

Serum electrolytes :

Sodium -136

Potassium -3.8

Chlorides-98

Cell count of asicitic fluid 

Appears : slightly cloudy

Colour : pale yellow

Total count: 480 cells / cumm

Neutrophils : 70

Lymphocytes : 30

Rbc : present

Treatment : 

Same treatment given 

Day 3 : 

Passed stools today

O/e : pt is concious , icterus +

Pr : 100 bpm

BP : 130/80mmhg

Cvs : S1 S2+ , no murmurs

Rs : bae + , CNS : no FND

P/A :  Distended  ,  tenderness + in RT hypochondrium and epigastric region

And girth : 86cms

Wt : 56 kgs

Investigations :

Serum electrolytes : 

Sodium - 138

Potassium - 3.3

Chloride - 98

LFT : 

TB - 9.62

DB - 6.79

AST - 84

ALP - 524

TP - 4.7

Albumin - 2.06

Hemogram : 

Total count : 14,000

PCV - 28.7

MCHC - 36.4

RDW CV - 15.2

Rbc - 3.27

Treatment : 

Same treatment given + inj cefotaxime 2g IV / BD

Day 4: 

No fever spikes , pt is subjectively feeling better , passed stools 3times 

O/e : pt is concious , oriented to time , place , person 

Abd girth : 92cms

Wt : 52kgs

I/o : 620/900ml

Pr : 92bpm

BP : 150/90 mmHg

CVS : S1 S2 + ,. CNS : no FND

RS : bae + , fine crepts + in ISA , IAA

P/A : distended , guarding +, tenderness in epigastrium , hypochondrium 

Percussion : tympanic 

Fluid thrill - negative , BS- negative

Investigations : 

Serum electrolytes :

Sodium - 137

Potassium- 4.8

Chloride - 99

Serum creatinine - 0.8

Blood urea - 65

Hemogram -

Total count - 11,600

PCV - 28.9

MCHC - 36.5

RDW CV - 15.6

Rbc - 3.33 million/ cumm

Treatment 

Same treatment given 

Diagnosis : 

Decompensated liver disease with  ? portal hypertension with thrombocytopenia , hepatic encephalopathy ( resolved ) .