[03-04-2025 10:38] PPM 1: Please share the updated fever chart and his ascitic fluid cell type and cell counts sent yesterday @~PPM10 @~PPM9
[03-04-2025 10:39] PPM 1: Let's not measure abdominal girth as it may not help anywhere close to daily weight record
[03-04-2025 10:41] PPM 1: @~PPM10 if the ascitic fluid counts come normal since day before yesterday when he developed the fever spike then the spike would be more likely to be due to his thrombophlebitis and the fever in thrombophlebitis comes down once the iv is removed. In that case our ceftriaxone too would be an overkill
[03-04-2025 13:33] PPM 10: Yesterday they told that hod sir will see it and give report today
[03-04-2025 14.24] PPM 1: Fever spikes nil today. Yet to collect the ascitic fluid report to check if it was SBP!
EMR summary:
Age/Gender: 39 Years/Male
Address:
Discharge Type: Relieved
Admission Date: 28/03/2025 12:53 PM
Name of Treating Faculty
(AP) (PG3) (PG2) (PG1) (PG1)
Diagnosis
DECOMPENSATED CHRONIC LIVER DISEASE WITH ASCITES SECONDARY TO ALCOHOL ESOPHAGEAL VARICES (EV LIGATION DONE ON 07/05/2024)
UMBILICAL HERNIA
NO HEPATIC ENCEPHALOPATHY
Case History and Clinical Findings
PATIENT CAME WITH COMPLAINTS OF ABDOMINAL DISTENSION SINCE 2 YEARS.C/O SWELLING IN UMBILICAL REGION SINCE 9 MONTHS.
HOPI:PATIENT WAS APPARENTLY ASYMPTOMATIC 2 YEARS BACK THEN NOTICED DISTENSION OF ABDOMEN INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE NO Aggravating OR RELEIVING FACTORS ASSOCIATED With SWELLING IN Umbilical REGION INSIDIOUS IN ONSE GRADUALLY PROGRESSIVE IN NATURE AGGREVATED ON COUGH NO RELIEVING FACTOR NOT ASOCIATED WITH PAIN.H/O BILATERAL PEDAL EDEMA EXTENDING UPTO KNEE INSIDIOUS IN ONSET PROGRESSIVE NO AGGREVATING OR RELIEVING FACTORS.H/O DECREASED URINE OUTPUT.NO H/O CONFUSION, HEMATURIA.NO H/O FACIAL PUFFINESS,FEVER,ABDOMINAL PAIN,NAUSEA,VOMITING,CONSTIPATION,LOOSE STOOLS,.NO H/O HEMATEMesIS,MELENA,DYSPHAGIA,CHEST PAIN,PND,ORTHOPNEA.
PAST HISTORY:K/C/O CHRONIC LIVERDISEASE SINCE 2 YEARS N/K/C/O T2DM/HTN/TB/EPILEPSY/THYROID/CVA/CAD
PAST MEDICAL HISTORY: 2 UNITS OF PRBC TRANSFUSION ON MAY 2024 OUTSIDE HOSPITAL
ESOPHAGEAL VARICES LIGATION ON 07/05/24 PERSONAL HISTORY:
MIXED DIET NORMAL APPETITE
BOWEL HABIT NORMAL
BLADDER DECREASED URINE OUTPUT ADEQUATE SLEEP
CHRONIC ALCOHOLIC SINCE 20 YEARS STOPPED 2 YEARS BACK CHRONIC SMOKER SINCE 20 YEARS STOPPED 2 YEARS BACK FAMILY HISTORY NOT SIGNIFICANT
GENERAL EXAMINATION PATIENT IS C/C/C
B/L PITTING PEDAL EDEMA EXTENDING TO KNEE PRESENT NO PALLOR NO ICTERUS NO LYMPHADENOPATHY NO CLUBBING
PR 94BPM
BP 110/70 MM OF HG RR 20CPM
SYSTEMIC EXAMINATION
CVS S1S2 HEARD NO MURMUR
RS BILATERAL AIR ENTRY PRESENT NVBS + CNS NFND
P/A :
INSPECTION : ABDOMEN DISTENDED UMBILICUS CENTRAL AND SWELLING OF UMBILICUS MEASURING 3X4CM WITH COUGH IMPULSE LIKELY UMBILICAL HERNIA.ALL QUADRANTS OF ABDOMEN MOVING ACCORDINGLY WITH RESPIRATION.
PALPATION: ABDOMEN SOFT NON TENDER.
PERCUSSION:DULL NOTE DETECTED OVER ENTIRE ABDOMEN D/T GROSS ASCITES.FLUID THRILL ELICITED.SHIFTING DULLNESS +
AUSCULTATION BOWEL SOUNDS HEARD.
SURGERY REFERRAL DONE I/V/O UMBILICAL HERNIA:
IMPRESSIVE : UMBILICAL HERNIA REPAIR ONCE PATIENT IS STABILISED. COURSE IN THE HOSPITAL:
39 YEARS OLD MALE CAME WITH ABOVE MENTIONED COMPLAINTS.NECCESSARY INVESTIGATIONS WERE DONE AND WAS DIAGNOSED AS DECOMPENSATED CHRONIC LIVER DISEASE SECONDARY TO ALCOHOL ,ESOPHAGEAL VARICES ,UMBILICAL HERNIA,NO ENCEPHALOPATHY WITH CHILD PUGH SCORE OF 8, MELD NA SCORE OF 8 MELD SCORE OF 11.TOTAL 4 DIAGNOSTIC AND THERAPEUTIC ASCITIC TAP WAS DONE AND ASCITIC FLUID WAS SENT FOR SAAG,AMYLASE,LIPASE,LDH,ALBUMIN,CELL COUNT
,CYTOLOGY.WEIGHT ON ADMISSION 70KGS AND ABDOMINAL GIRTH 104CMS.ON DISCAHRGE WEIGHT 62KGS AND ABDOMINAL GIRTH 94.5 CMS.H/O FEVER SPIKE AFTER 3RD ASCITIC TAP FOR WHICH INJ MONOCEF 2GM IV/BD WAS STARTED FOR TWO DAYS NO FEVER SPIKE LATER. PATIENT WAS TREATED CONSERVATIVELY AND HEMODYNAMICALLY STABLE HENCE BEING Discharged.
Investigation
BLOOD UREA28-03-2025 03:14:PM14 mg/dl42-12 mg/dl SERUM CREATININE28-03-2025 03:14:PM0.8 mg/dl1.3-0.9 mg/dL SERUM ELECTROLYTES (Na, K, C l) 28-03-2025 03:14:PM SODIUM138 mmol/L145-136 mmol/LPOTASSIUM4.5 mmol/L5.1-3.5 mmol/LCHLORIDE106 mmol/L98-107 mmol/LLIVER FUNCTION TEST (LFT) 28-03-2025 03:14:PM Total Bilurubin1.81
mg/dl1-0 mg/dl Direct Bilurubin0.40 mg/dl0.2-0.0 mg/dl SGOT(AST)47 IU/L35-0 IU/LSGPT(ALT)31 IU/L
45-0 IU/L
ALKALINE PHOSPHATASE168 IU/L280-53 IU/L
TOTAL PROTEINS6.4 gm/dl8.3-6.4 gm/dlALBUMIN2.0 gm/dl5.2-3.5 gm/dlA/G RATIO0.45STOOL FOR OCCULT BLOOD29-03-2025 11:11:AM
Positive LIVER FUNCTION TEST (LFT) 30-03-2025 07:45:AM Total Bilurubin1.18 mg/dl1-0
mg/dl direct Bilurubin0.25 mg/dl0.2-0.0 mg/dl
SGOT(AST)36 IU/L
35-0 IU/L
SGPT(ALT)23 IU/L
45-0 IU/L
ALKALINE PHOSPHATASE135 IU/L280-53 IU/LTOTAL PROTEINS5.6 gm/dl8.3-6.4 gm/dlALBUMIN2.0 gm/dl5.2-3.5 gm/dl A/G RATIO0.44BLOOD UREA30-03-2025 07:45:AM12 mg/dl
42-12 mg/dl
SERUM CREATININE30-03-2025 07:45:AM0.8 mg/dl1.3-0.9 mg/dl
SERUM ELECTROLYTES (Na, K, C l) 30-03-2025 07:45:AM SODIUM137 mmol/L145-136
mmol/LPOTASSIUM3.5 mmol/L5.1-3.5 mmol/LCHLORIDE100 mmol/L98-107 mmol/L
SERUM ELECTROLYTES (Na, K, C l) 30-03-2025 12:04:PM SODIUM136 mmol/L145-136
mmol/LPOTASSIUM3.7 mmol/L5.1-3.5 mmol/LCHLORIDE101 mmol/L98-107 mmol/L
BLOOD UREA30-03-2025 10:28:PM16 mg/dl42-12 mg/dl
SERUM CREATININE30-03-2025 10:29:PM0.7 mg/dl1.3-0.9 mg/dl SERUM ELECTROLYTES (Na, K, C l) 30-03-2025 10:29:PM SODIUM139
mmol/L145-136 mmol/LPOTASSIUM3.8 mmol/L5.1-3.5 mmol/LCHLORIDE103 mmol/L98-107 mmol/LLIVER FUNCTION TEST (LFT) 30-03-2025 10:29:PM Total Bilurubin1.01 mg/dl1-0 mg/dlDirect Bilurubin0.20 mg/dl0.2-0.0 mg/dl SGOT(AST)43 IU/L35-0 IU/LSGPT(ALT)26 IU/L45-0 IU/LALKALINE PHOSPHATASE152 IU/L280-53 IU/LTOTAL PROTEINS6.1 gm/dl8.3-6.4 gm/dlALBUMIN2.0 gm/dl5.2-3.5 gm/dl A/G RATIO0.49SERUM ELECTROLYTES (Na, K, C l) 01-04- 2025 11:48:PM SODIUM136 mmol/L145-136 mmol/LPOTASSIUM4.2 mmol/L5.1-3.5 mmol/LCHLORIDE100 mmol/L98-107 mmol/LBLOOD UREA01-04-2025 11:48:PM20 mg/dl42-12
mg/dl SERUM CREATININE01-04-2025 11:48:PM0.9 mg/dl1.3-0.9 mg/dl HEMOGRAM ON 28/3/25
HAEMOGLOBIN 7.7 gm/dl TOTAL COUNT 3,400 cells/cumm NEUTROPHILS 53 % LYMPHOCYTES 33 % EOSINOPHILS 06 % MONOCYTES 08 % BASOPHILS 00 % PCV 23.2 vol % M C V 77.9 fl M C H 25.8 pg M C H C 33.2 % RDW-CV 18.1 % RDW-SD 51.7 fl RBC COUNT 2.98
millions/cumm PLATELET COUNT 1.2 lakhs/cu.mm RBC predominently Normocytic, normochromic with few macrocytes, microcytes torget cellsWBC In adeqaute PLATELETS Adeqaute HEMOPARASITES No hemoparasites seen IMPRESSION bicytophenia.
HEMOGRAM ON 30//3/25
HAEMOGLOBIN 7.5 gm/dl TOTAL COUNT 3,000 cells/cumm NEUTROPHILS 47 % LYMPHOCYTES 37 % EOSINOPHILS 06 % MONOCYTES 10 % BASOPHILS 00 % PCV 22.2 vol % M C V 77.6 fl M C H 26.2 pg M C H C 33.8 %RDW-CV 17.6 % RDW-SD 50.5 fl RBC COUNT 2.86
millions/cumm PLATELET COUNT 1.16 lakhs/cu.mmRBC predominently Normocyticnormochromic with few macrocytesmicrocytes torget cellsLight MicroscopyWBC Decreased on smear PLATELETS In Adequate HEMOPARASITES No hemoparasites seen IMPRESSION Bicytophenia
HEMOGRAM ON 31/3/25
HAEMOGLOBIN 7.5 gm/dl TOTAL COUNT 3,000 cells/cumm NEUTROPHILS 47 % LYMPHOCYTES 37 %EOSINOPHILS 06 %MONOCYTES 10 % BASOPHILS 00 %PCV 22.2 vol % M C V 77.6 fl M C H 26.2 pg M C H C 33.8 % RDW-CV 17.6 % RDW-SD 50.5 fl RBC COUNT 2.86
millions/cummPLATELET COUNT 1.16 lakhs/cu.mm RBC predominently Normocyticnormochromic with few macrocytesmicrocytes torget cellsLight MicroscopyWBC Decreased on smear Light MicroscopyPLATELETS In Adeqaute Light MicroscopyHEMOPARASITES No hemoparasites seen Light MicroscopyIMPRESSION Bicytophenia
HEMOGRAM ON 01/4/25
HAEMOGLOBIN 8.0 gm/dl TOTAL COUNT 3,300 cells/cumm NEUTROPHILS 40 %LYMPHOCYTES 40 % EOSINOPHILS 10 % MONOCYTES 10 % BASOPHILS 00 % PCV 23.5 vol %M C V 76.5 fl M C H 26.1 pg M C H C 34.0 % RDW-CV 17.7 % RDW-SD 50.4 fl RBC COUNT 3.06 millions/cumm
PLATELET COUNT 92,000 lakhs/cu.mm RBC Normocytic normochromic with fewmicrocytesWBC Decreased counts on smear PLATELETS In AdeqauteHEMOPARASITES No hemoparasites seenIMPRESSION pancytopenia
HEMOGRAM 03/4/25
HAEMOGLOBIN 7.8 gm/dl TOTAL COUNT 2,400 cells/cumm NEUTROPHILS 64 % LYMPHOCYTES 21 % EOSINOPHILS 05 % MONOCYTES 10 % BASOPHILS 00 % PCV 23.4 vol % M C V 78.0 fl M C H 26.0 pg M C H C 33.3 % RDW-CV 18.1 % RDW-SD 52.6 flRBC COUNT 3.00
millions/cummPLATELET COUNT 72,000 lakhs/cu.mm RBC Normocytic normochromic with fewmicrocytes WBC decreased counts on smear PLATELETS Inadequate HEMOPARASITES No hemoparasites seen IMPRESSION pancytopenia
28/3/25: INR 1.11 APT 32SEC PT 16 SEC BT 2 MIN CT 4 MIN SR LDH 350
28/3/25 ASCITIC FLUID ANALYSIS :
PROTIEN 0.9 SUGAR 101 AMYLASE 202 LDH 130.8 ALBUMIN 0.37 SAAG 1.63 CELLS NIL CLEAR PALE YELLOW
ASCITIC FLUID CYTOLOGY ON 2/4/25 SCANT CELLULAR CYTOSMEAR SHOWS MESOTHELIAL CELLS FEW REACTIVE MESOTHELIAL CELLS AND LYMPHOCYTES.NO EVIDENCE OF ATYPICAL CELLS IN SMEAR STUDIED.
USG ABDOMEN ON 28/3/25
CIRRHOSIS OF LIVER WITH PORTAL HTN,UMBILICAL HERNIA 19 MM DEFECT,GROSS ASCITES,SPLENOMEGALY.
Treatment Given(Enter only Generic Name)
1. FLUID RESTRICTION <1.5 L/DAY
2. SALT RESTRICTED DIET <2GM/DAY
3. TAB FUROSEMIDE 40MG PO/OD
4. TAB ALDACTONE 100MG PO/OD
5. TAB PROPRANOLOL 20MG PO/BD
6. HEPATIC PROTIEN POWDER 2 SCOOPS IN 200 ML MILK
7. 3 EGG WHITE PER DAY
8. WEIGHT AND ABDOMINAL GIRTH MONITORING
9. SYP LACTULOSE 15ML/TID
Advice at Discharge
1. FLUID RESTRICTION <1.5 L/DAY TO BE CONTINUED
2. SALT RESTRICTED DIET <2GM/DAY TO BE CONTINUED
3. TAB ALDACTONE 100MG PO/OD X2 WEEKS
4. TAB PROPRANOLOL 20MG PO/BD X2WEEKS
5. HEPATIC PROTIEN POWDER 2 SCOOPS IN 200 ML MILK X2WEEKS
6. 3 EGG WHITE PER DAY TO BE CONTINUED
7. SYP LACTULOSE 15ML/TID X 1 WEEK
Follow Up
REVIEW TO GENERAL MEDICINE OPD AFTER 2 WEEKS /SOS REVIEW TO GENERAL SURGERY OPD AFTER 2 WEEKS /SOS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE, DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care, when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER
SIGNATURE OF PG/INTERNEE
SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
Discharge Date Date:07/04/25 Ward:MMW Unit:4
