ALCOHOLIC LIVER DISEASE

WITH ASCITES
D.DEEKSHITHA
REG.NO-618189802002
PHARMD III/VI
NAME OF THE PATIENT-P LAKSHMI NARAYANA AGE-47 SEX-M

IPD/OPD.NO-2410 DEPARTMENT-GENERAL MEDICINE

D.O.A-4-7-19 WARD-MMW UNIT-I PLACE-SRIKAKULAM

REASON FOR ADMISSION-
ABDOMINAL DISTENSION SINCE 6 DAYS
DECREASED URINE OUTPUT AND BOWEL FREQUENCY
LOW BACK PAIN SINCE 6 DAYS
PRURITUS '+'

HISTORY OF PRESENT ILLNESS-

ABDOMINAL DISTENSION SINCE 6 DAYS
INSIDIOUS IN ONSET,GRADUALLY PROGRESSIVE ASSOCIATED WITH LOW BACK PAIN
DECREASED URINE OUTPUT AND BOWEL FREQUENCY
PRURITUS'+'
HISTORY OF PAST ILLNESS-
H/O SIMILAR COMPLAINTS MULTIPLE TIMES IN THE PAST
NOT A KNOWN HTN,DM
NO H/O TB,ASTHMA AND EPILEPSY
GENERAL EXAMINATION- SYSTEMIC EXAMINATION-
P-(+) CVS-S1S2(+)
I-(+) Rs-B/L NVBS(+)
C-(-) ABDOMEN-DISTENDED FLUID THRILL
K-(-) CNS-(N)NORMAL
L-(-) LEVEL OF CONSCIOUSNESS-CONSCIOUS
E-(+) SPEECH-(N)
MALNUTRITION-(+) NECK STIFFNESS-NO
NO DEHYDRATION KERNIG'S SIGN-NO
TEMP-AFEBRILE CRANIAL NERVES,GLASSGOW SCALE-(N)
PR-80bpm REFLEXES-(N)
BP-110/80mmHg SENSORY SYSTEM-(N)
PROVISIONAL DIAGNOSIS-
ALCOHOLIC LIVER DISEASE WITH ASCITES

INVESTIGATIONS ORDERED-
Hb,TLC,CBC,RFT,LFT,RBS AND SEROLOGY
LABORATORY INVESTIGATIONS-
TEST RESULT NORMAL RANGE
Hb 6.1 gms % (12-14)
TWBC 3,600 Cells/Cumm (4k-11k)
DIFFERENTIAL COUNT P-60% L-32% E-08%
ESR 19mm/1St HR (0-10)
PLATELET COUNT 1.4 Lakhs/Cumm (1.5-4.5)
PCV 19 mm (35-45)
TRBC 2.2 millions/Cumm (35-55)
MCV 88 fl (92-98)
MCH 27.5 pg (29-32)
MCHC 31.1 g/l (33-48)
 TEST RESULT NORMAL RANGE
GLUCOSE 124mg/dl (70-140)
UREA 34mg/dl (15-40)
CREATININE 0.9mg/dl (0.5-1.5)
TOTAL BILIRUBIN 0.7mg/dl (0.2-1.0)
DIRECT BILIRUBIN 0.3mg/dl (0-0.4)
SGOT 25 u/l (5-34)
SGPT 16 u/l (0-40)
ALP 106 u/l (36-113)
TOTAL PROTEINS 6.5g/dl (6-8)
ALBUMIN 1.4g/dl (3.5-5)
 DRUG TREATMENT CHART
DRUG DOSE ROUTE FREQUENCY DAY-1 DAY-2 DAY-3 DAY-4 DAY-5 DAY-6 DAY-7 DAY-8 DAY-9
INJ CEFTRIAXONE 1gm IV BD * *
INJ PANTOP 40mg IV BD * * * * * * * * *
INJ LASIX 20mg IV OD * * * * * * *
INJ D5WITH MVI IV * * * * * *
IVF-1NS,1DNS IV * *
T BC ORAL OD * * * * * * * * *
T UDILIV ORAL BD * * * * * * * * *
ASCITIC TAP * * *
SYP LACTULOSE 15ml ORAL BD * *
T DULCOLAX ORAL BD * * * *
BLOOD TRANSFUSE 1U *
FOLLOW UP
DAYS OBSERVATION TREATMENT
GC-CONSCIOUS INJ CEFTRIAXONE 1gm IV BD
CVS-S1S2(+) INJ PANTOP 40mg IV OD
PR-80bpm INJ LASIX 20mg IV BD
DAY-1 Rs-B/L NVBS(+) INJ D5 WITH MULTIVITAMIN INJECTION
P/A- ABDOMEN DISTENDED IVF 1NS,1DNS
T BC OD
T UDILIV BD
GC-CONSCIOUS INJ CEFTRIAXONE 1gm IV BD
BP-110/90mmHg INJ PANTOP 40mg IV OD
CVS-S1S2(+) INJ LASIX 20mg IV BD
DAY-2 PR-68bpm INJ D5 WITH MULTIVITAMIN INJECTION
Rs-B/L NVBS(+) IVF 1NS,1DNS
P/A- ABDOMEN DISTENDED T BC OD
NO TENDERNESS T UDILIV BD
ASCITIC TAP
DAYS OBSERVATION TREATMENT
GC-CONSCIOUS
CVS-S1S2(+) INJ PANTOP 40mg IV OD
PR-80bpm INJ D5 WITH MULTIVITAMIN INJECTION
DAY-3 Rs-B/L NVBS(+) INJ LASIX 20mg IV BD
BP-110/70mmHg T BC OD
P/A-ABDOMEN DISTENDED T UDILIV BD
NO TENDERNESS
GC-CONSCIOUS
CVS-S1S2(+) INJ PANTOP 40mg IV OD
PR-70bpm INJ LASIX 20mg IV BD
DAY-4 BP-110/70mmHg INJ D5 WITH MULTIVITAMIN
Rs-B/L NVBS(+) INJECTION
P/A- ABDOMEN T BC OD
DISTENDED T UDILIV BD
NO TENDERNESS ASCITIC TAP
DAYS OBSERVATION TREATMENT
GC-CONSCIOUS INJ PANTOP 40mg IV OD
CVS-S1S2(+) INJ D5 WITH MULTIVITAMIN INJECTION
PR-78bpm INJ LASIX 20mg IV BD
DAY-5 Rs-B/L AE(+) T BC OD
BP-110/70mmHg T UDILIV BD
P/A-ABDOMEN DISTENDED SYP LACTULOSE 15ml BD

GC-CONSCIOUS
CVS-S1S2(+) INJ PANTOP 40mg IV OD
PR-84bpm INJ LASIX 20mg IV BD
DAY-6 BP-110/70mmHg T DULCOLAX 2 TAB H/S
Rs-B/L AE(+) SYP LACTULOSE 15ml BD
P/A- ABDOMEN T BC OD
DISTENDED T UDILIV BD
ASCITIC TAP
DAYS OBSERVATION TREATMENT
GC-CONSCIOUS INJ PANTOP 40mg IV OD
CVS-S1S2(+) INJ LASIX 20mg IV BD
PR-80bpm T BC OD
DAY-7 Rs-B/L AE(+) T UDILIV BD
BP-90/70mmHg T DULCOLAX 2 TABS H/S
P/A-ABDOMEN DISTENDED

GC-CONSCIOUS
CVS-S1S2(+) INJ PANTOP 40mg IV OD
PR-80bpm T DULCOLAX 2 TAB H/S
DAY-8 BP-90/80mmHg T BC OD
Rs-B/L AE(+) T UDILIV BD
P/A- SOFT PLAN 1 UNIT CELL BLOOD TRANSFUSION
NO ORGANOMEGALY
GC-CONSCIOUS
CVS-S1S2(+) INJ PANTOP 40mg IV OD
PR-70bpm T DULCOLAX 2 TAB H/S
DAY-8 BP-100/80mmHg T BC OD
Rs-B/L NVBS(+) T UDILIV BD
P/A- DISTENDED