65 YEAR OLD MALE WITH DISTENDED ABDOMEN
Elog
26th sept 2022
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Chief complaint
Patient is a 65 year old, water plant worker from bhongir
1. SOB since 2 years
2. Distended abdomen since 6 months
3. Swollen legs since ?
History of present illness
Patient was apparently asymptomatic 2 years ago when he developed SOB which didnot hinder his daily activities so the patient didn't recieve any treatment
6 months back, the patient was having a distended abdomen and was experiencing sob even after a short walk for which he visited a local hospital where he was administered glucose and recieved 2 units of blood transfusion
His SOB and edema in legs and the abdominal distention aggravated since 15 days, patient started experiencing sob even on sitting
He also had diarrhea since 4 days
Fever since 3 days, according to the patient, temperature was apparently high during the day and reduced during the evening time
History of past illness
1. DM since 2 years, for which medication(metformin) was used only for an year and later refused to take any medicine
2. HTN since 2 years
3. 25 to 30 years back the patient apparently fell from the train and had a major crack in the skull for which he didnot recieve any surgery?
Following the injury, the patient's speech was apparently incoherent or not making any sense for one year
4. 12 years back he had an episode of paralysis in his right upper limb for which he was initially given 2 injections on the same day at a hospital in Hyderabad which relieved his attack and further used ayurvedic medicine for 5 years (but the course given was for only 3 years)
Personal history
Appetite - REDUCED
Sleep - DISTURBED
Bowel movements - Normal
Micturition - normal
Alcohol intake -- regular consumption of whiskey since 40 years
(death of his wife 20 years back and death of his son 5 years back lead to further increase in the frequency of alcohol consumption)
Smoking since 30 years
Family history
Mother and brother had DM
Surgical history
NO HISTORY OF SURGERIES
was denied knee surgery due to his head injury in the past
Treatment history
● Metformin was prescribed for diabetes which he used only for an year
●Medication for hypertension was also prescribed since 2 years
●Takes B complex tablets occasionally whenever he notices fissures on his toungue
●Recieved 2 units of blood transfusion 6 months back
●Has been on ayurvedic medication for 5 years which was prescribed for 3 years for his paralysis
GENERAL EXAMINATION
Pallor - present
Icterus - absent
Cyanosis - absent
Kolionychia - absent
Lymphadenopathy - absent
Edema - Present (pitting type of edema)(grade 2?)
Reports
TREATMENT
DAY 1
Inj Lasix 40 mg IV BD
Tab aldactone 50mg PO OD
Tab UDILIV 300mg
Tab HEPAMERZ 500mg
Inj HAI
Lactulose 15ml
GRBS monitored 6th hourly
Foley's catheterization
Inj THIAMINE 200mg in 50ml NS IV BD
Inj VIT K in 50 ml NS
Fluid restriction <1.5 lts/day
DAY 2
Inj LASIX 40mg
Inj VIT K 10 ml
Inj THIAMINE 200 mg
Tab ALDACTONE 50 mg PO BD
Tab RIFAGUT 550 mg PO BD
Tab HEPAMERZ 500mg PO OD
Syp LACTULOSE 15ml
Syp POTCHLOR 10ml in one glass of water
DAY 3
Inj LASIX 40mg
Inj VIT K 10 ml
Inj THIAMINE 200 mg
Tab ALDACTONE 50 mg PO BD
Tab RIFAGUT 550 mg PO BD
Tab HEPAMERZ 500mg PO OD
Syp LACTULOSE 30ml PO TID
Syp POTCHLOR 10ml in one glass of water
Inj CEFTRIOXONE 1gm IU BD
DAY 4
Inj LASIX 40mg
Inj VIT K 10 ml
Inj THIAMINE 200 mg
Tab ALDACTONE 50 mg PO BD
Tab RIFAGUT 550 mg PO BD
Tab HEPAMERZ 500mg PO OD
Syp LACTULOSE 30ml PO TID
Syp POTCHLOR 10ml in one glass of water
Inj CEFTRIOXONE 1gm IU BD
DAY 5
Inj LASIX 40mg
Inj VIT K 10 ml
Inj THIAMINE 200 mg
Tab ALDACTONE 50 mg PO BD
Tab RIFAGUT 550 mg PO BD
Tab HEPAMERZ 500mg PO OD
Syp LACTULOSE 30ml PO TID
Syp POTCHLOR 10ml in one glass of water
Inj CEFTRIOXONE 1gm IU BD
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