This is an online E log book to discuss our patients deidentified health data shared after taking his/her/guardians signed informed consent.

Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.

This E log book also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

CASE PRESENTATION:

A 45 year old female from yadagaripalli farmer by occupation came with chief complaints of abdominal distention , pedal edema and SOB from 4 days.

Patient was apparently asymptomatic 20 days back when she developed fever associated with chills & rigors and vomitings (2-3 episodes) for which she was taken to a local hospital.

There on routine investigations she was diagnosed with Anemia , Thrombocytopenia and mild jaundice and was treated symptomatically.

Mild relief with on & off SOB (Grade-2) was present until 4 days back when she developed B/L pitting type of pedal edema , extending upto abdomen with abdominal distention and increased SOB (Grade 2-3).

No h/o chestpain/palpitations/orthopnea/PND

No h/o pain abdomen/loose stools/constipation

No h/o decreased U.O/burning micturition

No other complaints


H/o hearing loss + (R>L) from 10 years of age

Not a k/c/o DM/HTN/Asthma/Epilepsy/CAD/TB


Mixed diet

Decresed appetite

Regular Bowel & Bladder habits

Occassional toddy drinker since 15 years (seasonal)

Occassional whisky drinking 180ml since 15 years and increased frequency to daily 180ml from last 2 months due to some family problems


O/E:

Pt c/c/c

Pallor +

Bilateral pedal edema + (pitting type)




No icterus,cyanosis,clubbing or lymphadenopathy.

Vitals:

PR: 120bpm

BP: 130/70 mmhg

RR: 17cpm

SPO2: 99% on room air



CVS: S1,S2 + , No murmurs

RS: BAE + , NVBS

P/A: Distended , NT , umbilicus inverted , shifting dullness + , BS +





CNS: NFND



INVESTIGATIONS:

Ultrasound abdomen:


















DIAGNOSIS:

Chronic liver disease with portal hypertension with anemia and Thrombocytopenia.

HCV reactive.

TREATMENT:

Tab . LASILACTONE 20/50 mg po BD

Tab . PAN 40mg OD

SYP . LACTULOSE 15ml PO BD

Tab . UDILIV 150mg BD

Salt restriction less than 2.4gm per day

Fluid restriction less than 1.5L per day

Daily weight and abdominal girth monitoring 

Bp/Pr/Temp/SpO2 monitoring 4th hourly

Strict I/O charting.



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