45 year old male with decompensated liver disease with portal hypertension,ascitis,bilateral lower limb cellulitis , alcohol dependence syndrome, hepatic encephalopathy(resolved) , uti and microscopic hematuria

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Here is a case i have seen:

A 45 year old male farmer by occupation presented to opd c/o bilateral pedal edema since 4 months

Abdominal distension since 4 months

Ulcer on left foot 15 days ago 

Patient was apparently asymptomatic 4 months back then he developed  b/l pedal edema which was insidious in onset pitting type associated with abdominal distension which was also insidious in onset for which he was admitted and got discharged 2 months back.patient developed ulcer over left foot 2 months back which was aggrevating in size in last 3-4 days associated with foul smelling 

No h/o palpitations, sweating, sob, chest pain and giddiness 

No h/o decreased urine output,burning micturition and facial puffiness

No h/o fever, vomitings, loose stools, hemetemesis, malena

He is a k/c/o chronic liver disease diagnosed 4 months back 

Past history:

H/o bleeding perrectum ?internal haemorrhoids 

Not a k/c/o Tb, asthma, dm, hypertension, 

Personal history:

Pt takes mixed diet 

Appetite normal 

Bowel and bladder movements are regular

Addictions: chronic alcoholic (whiskey) since 10-20 years daily intake 90-180 ml

?stopped 4 months back

O/E : pt is c/c/c

Pallor - absent 

Icterus -present

Cynosis -absent 

Clubbing - absent 

Lymphaenopathy -absent

Pedal Edema- present 

Vitals :

Afebrile on touch 

Pulse -78bpm

Bp- 110/80mmhg

RR-18cpm

CVS -s1s2 heard no murmers 

RS-b/l air entry present,Fine crepts heard in right infrascapular area

P/A: distended, non tender,no visible pulsations, no organomegaly

Bowel sounds heard 

Reports:

Usg abdomen:

F/s/o chronic liver disease

gross ascitis

gall bladder wall edema

Multiple collaterals over anterior abdominal wall

HIV 1/2 rapid test:negative

HBsAg rapid test:negative

Anti HCV antibodies rapid test:negative

Bleeding time:2min 30sec

clotting time:5min 00sec

APTT:35sec

Blood group:O+ve

Prothrombin time:17sec

INR:1.2

ECG:

2d echo:

Hemogram :

Serum electrolytes:

CUE:

Chest x ray:

Treatment:

Salt restriction(<2.4g/day)

Fluid restriction(<1.5L/day)

tab lasilactone(20/50)mg bd

Syp lactulose 15ml/po/bd

Tab rifiximine 550mg /po/bd

Syp hepamerz 15ml /po/bd

Inj thiamine 100mg in 100ml ns/iv /bd

Inj pan 40mg /od

Inj augmentin 1.2 gm/iv/bd

Inj optineuron 1amp in 100ml ns/iv/od

Tab udiliv 300mg /po/bd

Protein powder 2tsp in 100ml milk /po/bd

Maintain 2-3 stools per day

Grbs monitoring 8th hrly

Strict i/o charting

3 egg whites/day

1 unit prbc tranfused

Day 2

no fresh complaints 

No fever spikes

pt passed stools today morning once, 2 times yesterday 

O/e: pt c/c/c 

PR 74bpm

BP 110/80mmhg

Cvs s1s2 heard, no murmurs

RS-b/l air entry present,Fine crepts heard in right infrascapular area

P/A distended, non tender, bowel sounds heard

CNS: no FND

Reports:

LFT:

Total bilirubin:6.11

direct bilirubin:2.94

SGOT:54

SGPT:8

Alkaline phosphate:222

Total proteins:6.9

Albumin:1.64

A/G ratio:0.31

Serum albumib:1.66

Ascitic albumin:0.33

SAAG:1.34

Ascitic fluid for ldh:115

Serum ldh:265

Ascitic fluid protein:1.0

Ascitic fluid sugar:109

Ascitic fluid culture sensitivity:no growth after 4-8hrs of aerobic incubation 

Blood culture sensitivity: no growth after 24 hrs of aerobic incubation 

CUE:

surgery referal was done i/v/o bilateral lower limb cellulitis and daily dressings were done

Treatment:

Salt restriction(<2.4g/day)

Fluid restriction(<1.5L/day)

tab lasilactone(20/50)mg bd

Syp lactulose 15ml/po/bd

Tab rifiximine 550mg /po/bd

Syp hepamerz 15ml /po/bd

Inj thiamine 100mg in 100ml ns/iv /bd

Inj pan 40mg /od

Inj augmentin 1.2 gm/iv/bd

Inj metronidazole 500mg iv tid

Inj optineuron 1amp in 100ml ns/iv/od

Tab chymoral forte po tid

Inj piptaz 4.5gm iv stat

Tab udiliv 300mg /po/bd

Protein powder 2tsp in 100ml milk /po/bd

Maintain 2-3 stools per day

Grbs monitoring 8th hrly

Strict i/o charting

3 egg whites/day

ASD done at ulcer site

Day 3:

C/o pain al ulcer site(left lower limb)  

No fever spikes

pt passed stools today morning once, 2 times yesterday 

O/e: pt c/c/c 

PR 96bpm

BP 120/80mmhg

AG:88cm

Wt:67kg

astrexis:+

Apraxia:-

I/O:1000/1150

Cvs s1s2 heard, no murmurs

RS-b/l air entry present,Fine crepts heard in right infrascapular area

P/A distended, non tender, bowel sounds heard

CNS: no FND

Treatment:

Salt restriction(<2.4g/day)

Fluid restriction(<1.5L/day)

tab lasilactone(20/50)mg bd

Syp lactulose 15ml/po/bd

Tab rifiximine 550mg /po/bd

Syp hepamerz 15ml /po/bd

Inj thiamine 100mg in 100ml ns/iv /bd

Inj pan 40mg /od

Inj metronidazole 500mg iv tid

Inj optineuron 1amp in 100ml ns/iv/od

Tab chymoral forte po tid

Inj piptaz 4.5gm iv stat

syp potchlor 10ml in 1 glass of water/po/bd

Tab udiliv 300mg /po/bd

Protein powder 2tsp in 100ml milk /po/bd

Maintain 2-3 stools per day

Grbs monitoring 8th hrly

Strict i/o charting

3 egg whites/day

ointment mupirocin L/A

ASD done at ulcer site

Day 4

c/o chills

no fever spikes 

Passed stools

O/e: pt c/c/c 

PR 78bpm

BP 120/80mmhg

AG:88cm

Wt:67kg

astrexis:-

Apraxia:-

I/O:900/1300

Cvs s1s2 heard, no murmurs

RS-b/l air entry present,Fine crepts heard in right infrascapular area

P/A distended, non tender, bowel sounds heard

CNS: no FND

Treatment:

Salt restriction(<2.4g/day)

Fluid restriction(<1.5L/day)

tab lasilactone(20/50)mg bd

Syp lactulose 15ml/po/bd

Tab rifiximine 550mg /po/bd

Syp hepamerz 15ml /po/bd

Inj thiamine 100mg in 100ml ns/iv /bd

Inj pan 40mg /od

Inj metronidazole 500mg iv tid

Inj optineuron 1amp in 100ml ns/iv/od

Tab chymoral forte po tid

Inj piptaz 4.5gm iv stat

syp potchlor 10ml in 1 glass of water/po/bd

Tab udiliv 300mg /po/bd

Protein powder 2tsp in 100ml milk /po/bd

Maintain 2-3 stools per day

Grbs monitoring 8th hrly

Strict i/o charting

3 egg whites/day

ointment mupirocin L/A

2 ffps transfused

ASD done at ulcer site

2 ffps transfusion was done

day 5

c/o pain at ulcer site

No fever spikes 

O/E:

Afebrile on touch

Pt is c/c/c

PR:102bpm

BP:130/80

Spo2:98%

RR-18cpm

Grbs:83mg/dl

I/O:1200/800

AG:88cm

Weight:67kgs

CVS -s1s2 heard no murmers 

RS-b/l air entry present,Fine crepts heard in right infrascapular area

P/A: distended,soft, non tender,no visible pulsations, no organomegaly,Bowel sounds heard 

cns:no fnd

Reports:

PT:23sec

INR:1.7

APTT:46sec

Treatment:

Salt restriction(<2.4g/day)

Fluid restriction(<1.5L/day)

tab lasilactone(20/50)mg bd

Syp lactulose 15ml/po/bd

Tab rifiximine 550mg /po/bd

Syp hepamerz 15ml /po/bd

Inj thiamine 100mg in 100ml ns/iv /bd

Inj pan 40mg /od

Inj metronidazole 500mg iv tid

Inj optineuron 1amp in 100ml ns/iv/od

Tab chymoral forte po tid

Inj piptaz 4.5gm iv stat

syp potchlor 10ml in 1 glass of water/po/bd

Tab udiliv 300mg /po/bd

Protein powder 2tsp in 100ml milk /po/bd

Maintain 2-3 stools per day

Grbs monitoring 8th hrly

Strict i/o charting

3 egg whites/day

ointment mupirocin L/A

ASD done at ulcer site

1 unit prbc transfusion done

Day 6

C/o 2 episodes of bilious vomitings today morning

Passed stools 4 times yesterday,tody once 

O/E:

Afebrile on touch

Pt is c/c/c

PR:88bpm

BP:140/80

Spo2:98%

RR-18cpm

Grbs:110mg/dl

I/O:1100/1550

AG:90cm

Weight:67kgs

CVS -s1s2 heard no murmers 

RS-b/l air entry present,Fine crepts heard in right infrascapular area

P/A: distended,soft, tenderness present in epigastric region,no visible pulsations, no organomegaly

Bowel sounds heard 

CNS: no FND

Hemogram:

PT:25sec

INR:1.8

APTT:49sec

Treatment:

Salt restriction(<2.4g/day)

Fluid restriction(<1.5L/day)

tab lasilactone(20/50)mg bd

Syp lactulose 15ml/po/bd

Tab rifiximine 550mg /po/bd

Syp hepamerz 15ml /po/bd

Inj thiamine 100mg in 100ml ns/iv /bd

Inj pan 40mg /bd

Inj metronidazole 500mg iv tid

Inj optineuron 1amp in 100ml ns/iv/od

Tab chymoral forte po tid

Inj piptaz 4.5gm iv stat

inj zofer 4mg iv tid

tab buscopan po/bd

syp potchlor 10ml in 1 glass of water/po/bd

Tab udiliv 300mg /po/bd

Protein powder 2tsp in 100ml milk /po/bd

Maintain 2-3 stools per day

Grbs monitoring 8th hrly

Strict i/o charting

3 egg whites/day

ointment mupirocin L/A

ASD done at ulcer site

Ascitic paracentesis is done(500ml)