33 year old male came to the casuality with chief complaints of :
Abdominal distension since 2 months
B/L pedal edema since 2 months
Scrotal swelling since 2 months
HOPI :
33 year old male got married 9 years back , separated from his wife and children since 5 years due to family issues about which he's not willing to tell .
After separation with his wife ,patient started taking half a bottle of whisky every day .
3 years back he had history of abdominal distension and pedal edema for which he visited local hospital and was diagnosed as liver disease and used medication for a while and stopped , he was diagnosed as diabetic back then and on treatment metformin 500 mg .
8 months back :
He had abdominal distension and yellowish discoloration of eyes and used herbal medication - he did not get any relief for it , his symptoms got aggravated then he visited other hospital with the complaints of abdominal distension and SOB at rest , back then he was diagnosed as DCMP secondary to alcoholism with Chronic Liver Disease with Alcohol Dependence Syndrome with DM - 2
Patient stopped taking medication since 2 months followed which he started getting pedal edema which was insidious in onset and gradually progressive till the scrotum and abdominal distension till the xiphisternum .
Past history :
The patient has met with accidents once in 2011 and next in 2018 where his right side ribs were damaged and had a laceration on the right parietal bone area in the head which was sutured.
10 years ago he had a mass in the anal region - external hemorrhoids ?
He's a k/c/o DM -2 since 2 years and under treatment of Tab Metformin 500 mg
K/c/o HFrEF since 6 months , Chronic liver disease since 3 years
Last alcohol intake 6 days ago (quantity - 1 quarter )
Not a k/c/o tuberculosis , asthma ,epilepsy .
Personal history :
Occupation - sells plants
Diet - mixed
Appetite - decreased since 5-6 days
Sleep - decreased quality of sleep due to pain
Bowel and bladder habits - regular
Addictions : smoking since 10 years
Alcohol since 10 years
Family history : no significant family history
General examination :
Mild icterus present
Edema of feet - present
Scrotal swelling + abdominal distension
No H/O pallor , cyanosis , lymphadenopathy
Vitals :
Temp - febrile (99.2 degree Fahrenheit)
PR - 112 bpm
RR - 22 cpm
BP - 110/70 mmHg
SPO2 - 99 % at RA
GRBS - 175 mg/dl
Systemic examination :
CVS :
S1 S2 +
JVP - elevated
No parasternal heave /thrills
Apex beat - 5th ICS
RS :
BAE + , NVBS heard
P/A :
Abdomen - distended
Normal hernial orifices
Fluid thrill +
Dilated veins present
No tenderness
No palpable mass
No organomegaly
No bruit hear
CNS - no focal neurological deficit present
Diagnosis :
DCMP with reduced ejection fraction (<29 %)
with chronic liver disease with scrotal fascitis with right sided varicocele
Investigations :
Hemogram :
HB - 13
TLC - 12,100
N/L/E/M - 67 /20/10/3
PCV - 37.8
PLt - 3.13
RBC - 4.81
RFT :
Urea - 31
Creatinine - 0.7
Uric acid - 2.7
Calcium - 10
Phosphorous - 3.8
Sodium - 130
Potassium - 3.6
Chloride - 91
LFT :
TB - 7.26
DB -4.21
AST - 26
ALT - 17
ALP - 560
TP - 6.6
Albumin - 3.6
A/G ratio - 0.24
Ultrasound :
1.altered echotexture of liver with mild surface irregularity ?chronic liver disease
2.Raised echogenicity of B/L kidneys
3.Gall bladder wall edema
4.Gross ascites
5.Skin and subcutaneous tissue shows edematous changes in the anterior abdominal wall diffusely
Chest x-ray pa view
ECG
Treatment :
1.fluid restriction <1.5 l /day
2.salt restriction <2.4 g/day
3.Tab Lasix 40 mg po/bd
4.Tab Aldactone 50 mg po od
5.Tab Met xl 12.5 mg po bd
6.Tab Thiamine 100 mg po bd
7.daily weight and abdominal girth monitoring
8.I/O charting
9.Monitor vitals -4th hourly
10.Grbs - 6th hourly
11.inj HAI s/c according to sliding scale
Previously this patient was admitted in the month of June
https://pavankalyanc.blogspot.com/2021/06/a-35-year-old-male-resident-of.html?m=1
Surgery referral of this patient :
Psychiatry referral on 4/12/2021 :
Soap notes of 4/12/2021
S- pain in the scrotum intermittently
Abdominal distension +
O- pt is c/c/c
Afebrile
Pr 94/min
Bp 130/100 mmhg
Rr-20 cpm
Spo2 99% on room air
Cvs -s1s2+,jvp raised
Rs-bilateral air entry +
P/a -distended
Dilated veins +
Grbs -114
I/o-950/800
A- Heart failure with reduced ejection fraction with dilated cardiomyopathy
Decompensated liver disease
Diabetes mellitus with
Alcohol dependence
P-fluid and salt restriction
Inj lasix 40mg iv bd
Tab Aldactone 50mg po od
Tab carvidelol 3.125mg po od
Tab thiamine 100mg po bd
Tab metformin 500mg po od
Tab Ultracet 1/2 Tab po qid
Grbs 6th hrly
Daily wt and abd girth monitoring
I/O charting
Soap notes of 6/12/2021 :
SOAP notes
Ward
S - pain at scrotal region
SOB + since yesterday
Stools passed today
O - Pt is c/c/ c
Afebrile
PR - 90 bpm
BP - 110/70 mmHg
RR - 20 cpm
SPO2 -
CVS - S1 S2 +
CNS - NAD
RS - NVBS +
P/A - distended
Free fluid +
GRBS - 114 mg/dl
I/o - 700/1080 ml
Abd girth -108 cms
A- DCMP with decompesated liver disease with Diabetes mellitus 2 with alcohol and tobacco dependence syndrome
P -
1.Fluid and salt restriction
2.Inj Lasix 40 mg IV /BD
3.Inj VIT - B12 1000 mcg IM/OD
4.Tab Aldactone 50mg PO/OD .
5.Tab .Carvidelol 3.125 mg Po/OD
6.Tab thiamine 100 mg PO/OD
7.Tab Ultracef 1/2 PO Qid
8.Tab Metformin 500 mg PO/OD
9.Syp Lactulose 15ml PO/BD
10.weight and abdominal girth monitoring
11.I/O and temperature charting
Review USG of scrotum
Soap notes on 7/12/2021. :
SOAP notes
07/12/2021
Ward
33y/M
S -
Intermittent pain in scrotal region decreased compared to yesterday
SOB subsided
Stools passed today
O -
Pt is c/c/c
Afebrile
PR - 86 bpm
BP - 120/70 mmHg
RR - 18 cpm
SPO2 - 98% at RA
CVS - S1 S2 +
CNS - NAD
RS - NVBS +
P/A - distended
Free fluid +
Weight - 84 kgs
GRBS - 131 mg/dl
Abd girth -108 cms
A-
DCMP with decompesated liver disease with Diabetes mellitus 2 with alcohol and tobacco dependence syndrome
P -
1.Fluid and salt restriction
2.Inj Lasix 40 mg IV /BD
3.Inj VIT - B12 1000 mcg IM/OD
4.Inj. Ceftriaxone 1 gm IV/BD
5.Inj.Amikacin 500 mg IV/BD
6.Tab Aldactone 50mg PO/OD
7.Tab .Carvidelol 3.125 mg Po/OD
8.Tab. Thiamine 100 mg PO/OD
9.Tab. Ultracet 1/2 PO Qid
10.Tab.Levocitrizine 10 mg PO/BD
8.Tab Metformin 500 mg PO/OD
9.Syp Lactulose 15ml PO/BD
10.Weight and Abdominal girth monitoring
11.I/O and temperature charting
Abscess drainage :
Soap notes on 8/12/2021:
Ward
Bed no.1
SOAP notes
33 yr old male
S :
Intermittent pain in scrotum
SOB subsided
O-
Pt is c/c/c
Afebrile
Bp-120/80 mmHg
Pr -87 bpm
RR -18 cpm
SPO2 - 98%@RA
Weight -87 kgs
Abd girth - 105 cms
CVS - S1 S2 +
CNS - nad
R/s - NVBS +
P/a - distended
Free fluid +
A - DCMP with decompesated liver disease with DM type 2 with alcohol and tobacco dependence syndrome
1.fluid and salt restriction
2.inj Lasix iv/bd 8am (80 mg )- 4 pm (40 mg )
3.inj vit b12 1000 mcg IM/od
4.tab Aldactone 50 mg po/od
5.tab Carvidelol 3.125 mg po/od
6.tab thiamine 100 mg po/od
7.tab ultracet 1 po/qid
8.tab Metformin 500 mg po/od
9.syp Lactulose 15 ml po/hs
10.inj amikacin 1 gm in 100 ml ns over 2 hours iv/od
11.weight and abdominal girth monitoring
12.i/o and temperature charting
Soap notes on 9/12/2021 :
SOAP NOTES
09/12/2021
WARD
Bed no.1
33 yr old male
S :
Intermittent pain in scrotum
SOB subsided
O-
Pt is c/c/c
Afebrile
BP -120/80 mmHg
PR - 82 bpm
RR -18 cpm
SpO2 - 98%@RA
Weight - 87 kgs
Abdominal girth - 105 cms
CVS - S1 S2 +
CNS - NAD
RS - NVBS +
P/A - distended
Free fluid +
A - DCMP with decompesated liver disease with DM type 2 with alcohol and tobacco dependence syndrome
P:
1. Fluid and salt restriction
2. Inj Lasix iv/bd 8am (80 mg )- 4 pm (40 mg )
3. Tab Aldactone 50 mg po/od
4. Tab Carvidelol 3.125 mg po/od
5. Tab Thiamine 100 mg po/od
6. Tab Ultracet 1 po/qid
7. Tab Metformin 500 mg po/od
8. Syp Lactulose 15 ml po/hs
9. Inj Amikacin 1 gm in 100 ml ns over 2 hours IV / OD
10. Inj Tramadol 1 amp in 100 ml NS IV / BD
11. Inj Vit K 10 mg IM OD
12. Inj Metrogyl 100 ml IV/TID
11. Weight and abdominal girth monitoring
12. I/O and temperature charting
USG guided diagnostic ascitic tap was done.30 ml free fluid was aspirated and sent for investigation.
Cect abdomen
SOAP NOTES
10/12/2021
WARD
Bed no.1
33 yr old male
S :
Intermittent pain in the scrotum
C/o giddiness
O-
Pt is c/c/c
Afebrile
BP -130/80 mmHg
PR - 85 bpm
RR -17 cpm
SpO2 - 99%@RA
Weight - 87 kgs
Abdominal girth - 105 cms
CVS - S1 S2 +
CNS - NAD
RS - NVBS +
P/A - distended
Free fluid +
A - DCMP with decompesated liver disease with DM type 2 with alcohol and tobacco dependence syndrome
P:
1. Fluid and salt restriction. NBM since last night.
2. Inj Lasix iv/bd 8am (80 mg )- 4 pm (40 mg )
3. Tab Aldactone 50 mg po/od
4. Tab Carvidelol 3.125 mg po/od
5. Tab Thiamine 100 mg po/od
6. Tab Ultracet 1 po/qid
7. Tab Metformin 500 mg po/od
8. Syp Lactulose 15 ml po/hs
9. Inj Amikacin 1 gm in 100 ml ns over 2 hours IV / OD
10. Inj Tramadol 1 amp in 100 ml NS IV / BD
11. Inj Vit K 10 mg IM OD
12. Inj Metrogyl 100 ml IV/TID
11. Weight and abdominal girth monitoring
12. I/O and temperature charting
CECT is scheduled for today in view of omental thickening to rule out abdominal koch's radiologically.
SOAP NOTES
12/12/2021
WARD
Bed no.1
33 yr old male
S :
Intermittent pain in the scrotum decreased compared to yesterday
SOB subsided
O-
Pt is C/C/C
Afebrile
BP -120/80 mmHg
PR - 74 bpm
RR -18 cpm
SpO2 - 99% @ RA
Weight - 87 kgs
Abdominal girth - 105 cms
CVS - S1 S2 +
CNS - NAD
RS - NVBS +
P/A - distended, Free fluid +
Stools passed today
A - Ascites secondary to heart failure (CHF) with Scrotal pus
P -
1. Fluid and salt restriction.
2. Inj. Lasix IV/BD
8 am (80 mg )- 4 pm (40 mg )
3. Inj. Vitamin K 10 mg IM/OD
4. Tab Aldactone 50 mg po/od
5. Tab Carvidelol 3.125 mg po/od
6. Tab Thiamine 100 mg po/od
7. Tab Metformin 500 mg po/od
8. Tab Chymerol Forte PO/TID
9. Syp Lactulose 15 ml po/hs
10. Weight and abdominal girth monitoring
11. I/O and Temperature monitoring
SOAP NOTES
13/12/2021
WARD
Bed no.1
33 yr old male
S :
Intermittent pain in the scrotum decreased comparatively.
SOB subsided.
O-
Pt is C/C/C
Afebrile
BP -110/80 mmHg
PR - 78 bpm
RR -16 cpm
SpO2 - 99% @ RA
Weight - 87 kgs
Abdominal girth - 105 cms
CVS - S1 S2 +
CNS - NAD
RS - NVBS +
P/A - distended, Free fluid +
Stools passed today
A - Ascites secondary to heart failure (CHF) with Scrotal pus
P -
1. Fluid and salt restriction.
2. Tab Aldactone 50 mg po/od
3. Tab Carvidelol 3.125 mg po/od
4. Tab Thiamine 100 mg po/od
5. Tab Metformin 500 mg po/od
6.Tab Chymerol Forte PO/TID
7. Syp Lactulose 15 ml po/hs
Planning for discharge today.
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