A 42/M with abdominal distension since 4 days

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Chief complaints

A 42 year butcher came to casualty with

Lethargic since 1 week

Abdominal distension since 4 days

Not passing stools since 2 days

History of presenting Illness

4 years ago visited hospital in view of abdominal pain, epigastric region, non radiating, not associated with vomitings, there he was diagnosed with T2DM and was prescribed

T. Gliclazide 60 mg OD

10 days ago he visited hospital for Pain abdomen epigastric region, non radiating, not associated with vomitings and was prescribed

Inj.ISOPANE insulin 20-0-15

T. B-complex

SYP. Antacid

T. Ursodeoxycholic acid 300mg BD

T. Rabeprazole 20mg + levosulpride 75 mg OD

one week back then he had vomiting 3 episodes per day for 2 days,  non projectilee nonbilious contains food particles as contents non foul smelling, 

altered sleep cycle (sleeping during day, awake at night), yellowish discoloration of eyes.

From 4 days patient developed abdominal distension, incideous oncet, gradually progressed to the current size 82 cm not associated with abdominal pain, loose stools, fever 

From 2 days patient is not having appetite and not passing stools

No H/O of Hematemesis

No H/O bulky stools, black tarry, and clay coloured.

No H/O pruritus

No H/O fever with chills

No H/O frothy urine

No H/O haematuria, oliguria

No H/O blood transfusions

No H/O tattoo marking

No H/O loss of weight

No H/O HTN, TB, Hypo/Hyperthyroidism/ Epilepsy/Asthma/COPD/ CAD/ Blood transfusions

Family history

None of the patient’s parents, siblings or first degree relatives have or

have had similar complaints or any significant co morbidities

The CAGE assessment for alcohol dependency

C – Has never felt the need to Cut down alcohol consumption

A – Has felt Angry at others criticizing his drinking

G – never felt Guilty about excess drinking

E – drinks in the mornings (Eye-opener)

General examination

Ictrus +

There is No Pallor, cyanosis, koilonychias,

generalised lymphadenopathy and no pedal edema.

VITALS: 

GCS E4V4M5 

Temperature 98.5'F

Pulse 80 BPM

RR 15 Cycles/min

BP 110/70 mmHg

SpO2 98% at RA

P/A Examination:

INSPECTION:

Elliptical Distention of Abdomen

Flanks- full 

Umbilicus-  everted,

Movements simultaneously with respiration

Skin over abdomen:  smooth,

No engorged veins

PALPITATION:

Non tender

No local rosr of Temperature

No Guarding, Rigidity,

No palpable masses

No Fluid Thrill with legs extended

No visible Peristalsis.

No hepatomegaly

No splenomegaly

AUSCULATION:

Bowel Sounds feable

CVS- Normal S1 S2 heard, No murmurs.

Respiratory: Normal vesicular breath sounds, No adventitious sounds

CNS- No Facial asymmetry, all reflexes are normal

Hemogram 1 week ago

HB 12g%

TC 11,800 cells/cumm

PLT 1.78lac

RBS 1 week ago 310

Creatinine 1 week ago 0.87

S. Amylase 1 week ago 106

LFT 1 week ago

TB 4.2

DB 1.2

AST 20

ALT 25

ALP 117

TP 7.0

ALB 3.7

APTT 40 sec

PT 16.3

INR 1.3

CUE 1 week ago

ALB +

Sugar 1%

Bile salts +

Bile pigments +

Ultrasound abdomen 1 week ago

APPROX. 100 CC OF FREE FLUID NOTED IN ABDOMEN

Liver enlarged in size 19 cms with coarse echotexture.

ECG 1 week ago

DAY 1

RBS: 70mg/dl

BGT O+ positive

RFT

Blood Urea: 94 mg/dl 

S. Creatinine: 1.4 mg/dl

Na 130

K 4.4

Cl 94

Hemogram

HB 14.5

TC 26,900

MCV 85.1

PCV 39.4

MCH 31.3

MCHC 36.8

PLT 5.36

RDW 39.1

P.S NORMOCYTIC, NORMOCHROMIC with leucocytosis

ABG  SpO2 98% on RA(venous blood gas)

pH 7.38

PCo2 22.6

PaO2 35.8

HCO3 16.3

SpO2 55.6%

LFT

TB 3.79

DB 2.39

AST 77

ALT 25

ALP 225

TP 6.2

ALB 2.6

APTT 48 sec

PT 25

INR 1.8

CUE

ALB +

Sugars +

Pus cells 1-2

Epithelial cells 1-2

Serology -ve

Ultrasound abdomen

Moderate ascitis with Septation

Altered echotexture of liver

ECG

Chest X-ray

X-ray erect abdomen

DIAGNOSIS

Hepatic encephalopathy with alcoholic liver disease

Treatment

Inj. Monocef 2g IV BD 

INJ. Pan 40 IV OD

T. Rifagut 550mg RT BD

SYP. Lactulose 10 ml PO TID

T. Ursodeoxycholic acid 300 mg PO BD

Syp. Hepamez PO 10 ML BD

Inj. Vitamin K 10 mg over 10 min

SOAP NOTES DAY 1 

ICU BED NO. 2

New admission

SOAP NOTES             

S :  

Patient is intubated around 7-30 AM in view of hypoxia

O :

BP : non recordable mm hg ( NORADRENALINE 2 ml /hr, vasooresssin 1 ml/hr)

HR : 140 bpm 

GCS E1VTM1

Cvs : s1 s 2 +,

Rs : bae + nvbs + 

CNS : 

Tone hypotonic

  

Kernig sign negative

Brudzinski sign negative 

Doll eye could not be assessed as patient was given midazolem 2ml during intubation

RFT

urea 136

Creat 2.6

Na 127

k 5.6

Cl 98

ABG pre intubation

pH 7.23

Pco2 19.5

Hco3 11.6

Pao2 88.8

Spo2 90.9

ABG ON ventilator

pH 7.10

Pco2 28.0

Hco3 10.1

Pao2 282

Spo2 96.7

Ventilator settings

ACMV

RR 14

FIO2 80

PEEP 0

VT 420

Lipase 24

Amylase 38

Chest X-ray post intubation

ECG

A : Hepatic encephalopathy with alcoholic liver disease with type 1 respiratory failure with hyponatremia

Patient was intubated on 21/3/22 7-30 AM

Plan : 

IVF NS @ 50ml/hr

RT feeds 200ml milk 4th hrly

25D with 10U insulin

NEB. Duolin + mucomist

Inj. Monocef 2g IV BD 

INJ. Pan 40 IV OD

SYP. Lactulose 10 ml PO TID

Inj. Vitamin K 10 mg over 10 min

Triple lumen central line for ionotropes

Arterial line for BP monitoring