57 year ol man with jaundice ,pedal edema and abdominal distension since 3 years and bleeding gums since 3 days

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Here is a case i have seen:

A 57 year old male and RMP by occupation with 2 children 

Patient is chronic alcoholic since 40years daily 180ml of whisky taken and ocasionally toddy

Patient is non smoker,non diabetic and non hypertensive,no history of cad,cva tb, asthma

Pt is obese with gross abdominal obesity

Patient was apparently asymptomatic 3years ago then he noticed yellowish discoloration of eyes,bilateral pedal edema which is pitting type extending upto knees and abdominal distension 

Then he went to local hospital  and got lft  done which showed mild derangement 

Then he had bleeding gums and 2 days history of bilious vomitings ,no black stools 

Patient got endoscopy done which didnt show any varices according to history (report not available)

Pedal edema decreased after medications but always mild edema and abdominal distension were present

Patient didnt stop alcohol and continued taking it everyday . One and half year later patient developed gradual increase in right lower limb swelling which is pitting type extending upto upper thigh with gross swelling and skin thickening were present , local rise of temperature present , he even had blebs (no history of trauma)which he punctured himself later it got infected so he was taken to hospital in 2018 where he was started on antibiotics ,piptaz and albumin infusions 

Debridement was done

Reports in 2018:

Tb-2.20, DB-0.70,ALP-89,SGOT-22 ,SGPT-36

HB-13.7 ,TLC-4,800,PLT -4.8 Lakhs

S.creatinine -0.9,Na -138,K-3.9,Cl-101

Usg abdomen:

Moderate hepatosplenomegaly

Cholelithiasis(largest showing 6mm)

Small right renal calculus

Liver enlarged with coarse echotexture and nodular contour

2decho:normal

But swelling and skin thickening remained same  

Endoscopy was done 3yrs ago and 1 and half year back which was normal again according to his daughter 

No history of fever, pain abdomen or vomitings were present
Since 1 months patient was complaining of abdominal distension and shortness of breath on lying down and exertion
Patient attenders were giving history of multiple self medications whenever patient developed fever or shortness of breath they used to take decadron injections, larigo tablets,monocef and pantop over 4 months intermittently
Inspite of swelling and ulcerations patient used to do his regular activities and used to see opd ,no history of loss of appetite and used to ride bike and ho to hospital and going to washroom on his own
Since 1 month patient daughter giving history of forgetfulness ,depression and fear of dying
Since 5 days patient developed sudden increase in swelling of left lower limb with blebs,ulceration and increased temperature so he came to our hospital on Saturday and got dressing done
Since 1 week patient was bedridden and has generalised weakness and complaints of black stools intermittently
       23/9/2019      11/09             19/09           21/09
Hb- 12.4                     5.1                 4.8                3.6
Tlc - 4,600          8,800               9,400           10,600
Plt - 80,000          90,000           85,000          1 lakh
Esr on 11/09 - 90mm/hr

11/09 s.creat-1.2 (outside hospital)
Urea-39

LFT ON 11/09 (OUTSIDE HOSPITAL)
TB-5 , DB-2.3 ,ALP-102 ,SGOT -55 ,
SGPT -43 , Alb-4.3

19/09 (our hospital report)
TB-3.6 , DB -2.84 ,SGOT-36 ,SGPT-29
ALP-224 , ALB-1.6
19/09 :
PT -20sec
INR -1.4
APTT-38sec
SEROLOGY NEGATIVE

O/E : patient is conscious,coherent ,cooperative
Obese ,pallor present 

Icterus present

Clubbing absent 

Cyanosis absent

Pedal Edema present 

Lymphadenopathy absent 

Ulcer on right lower limb 

Hematoma on left lower limb over shin

VITALS:

Temp afebrile

bp-100/60 mmhg ,

PR - 120bpm
Spo2 -96% on room air ,

RR- 34 cpm
CVS -S1S2 heard no murmers 
RS-decreased air entry and bilateral fine crepitations are present in IAA,ISA,MA
P/A- grossly distended with flat umbilicus 

Bowel sounds present

Investigations:

Hb-3.6 

Tlc-10,600

Plt- 1 lakh
TB -2.75 ,DB- 2.43,ALP-213 ,ALB-1.4
SGOT-31 ,SGPT -26
Retic count - 1
PT - 35 
INR - 2.59
APTT - more than 1 min

RFT: 
Urea - 77 , creat-1.1 ,Na-129, K -4.4 ,Cl-98

Ecg

Usg abdomen:

F/s/o chronic liver disease

Mild splenomegaly

Moderate ascites

Ascitic tap done:

Ascitic albumin:0.33

SAAG : 1.3

Ascitic fluid for ldh:115

Ascitic ldh:265

Ascitic fluid protein:1.0

Ascitic fluid sugar:109

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

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

CUE

 pus cells 4-5

Albumin + 

Sugar - nil 

Treatment: 

Ecg is normal

high protein diet (2eggs / day)
1. Air or water bed
2. Fluid restriction <1.5litres/day
Salt restriction <2.4gms/day
3. Inj augmentin 1.2gm IV/BD
4. Inj pan 40 mg IV/OD
5. Inj zofer 4mg IV/BD
6. Tab lasilactone (20/50)mg BD
If SBP <90mmhg -avoid
7. Inj vit k 10mg IM/ STAT
8. Syp lactulose 15ml/PO/BD
9. Tab udiliv 300mg/PO/BD
10.syp hepameiz 15 ml/PO/OD
11.IVF 1 NS slowly at 30ml/hr
12. Inj thiamine 100mg in 100mlNS /IV/TID
13.strict BP/PR/TEMP/Spo2 CHARTING HOURLY
14.strict I/O charting
15.GRBS 6th hourly
16.protein x powder in glass of milk TID
17. 2FFP and 1PRBC transfusion

18 .ASD DONE

DAY2: no fresh complaints 

O/E: pt is conscious,coherent ,cooperative 

Asterixis present

Constructional apraxia

PR- 102 bpm ,low volume 

BP-100/70 mmhg ,RR-17 cpm
Spo2-97%on RA
CVS -S1S2 heard
RS-bilateral AE +
P/A- distended, nontender

Investigations:
1. Haemogram
Hb-3.4 gm/dl
Tlc-14,000 cells/cumm
Plt -90,000cells /cumm
2. PT -50sec
APTT- more than 1min
INR-3.7
3. S.urea-82 ,s.creat-1.5
4. Na-128 ,k -6 , cl -101 

5.usg abdomen 

6.2d echo findings:

7.ecg

Treatment:high protein diet (2eggs / day)
1. Air or water bed
2. Fluid restriction <1.5litres/day
Salt restriction <2.4gms/day
3. Inj augmentin 1.2gm IV/BD
4. Inj pan 40 mg IV/OD
5. Inj zofer 4mg IV/BD
6. Tab lasilactone (20/50)mg BD
If SBP <90mmhg -avoid
7. Inj vit k 10mg IM/ STAT
8. Syp lactulose 15ml/PO/BD
9. Tab udiliv 300mg/PO/BD
10.syp hepameiz 15 ml/PO/OD
11.IVF 1 NS slowly at 30ml/hr
12. Inj thiamine 100mg in 100mlNS /IV/TID
13.strict BP/PR/TEMP/Spo2 CHARTING HOURLY
14.strict I/O charting
15.GRBS 6th hourly
16.protein x powder 2 tablespoons in glass of milk PO/TID
17. 2FFP and 1PRBC transfusion
18.inj metrogyl 500mg IV/TID
19.tab rifaximin 550mg BD for 3days
20.inj tranexa 500mg iv OD 

21.ASD DONE

At 7:00 pm on 22/09/20
O/E: pt is conscious,coherent ,cooperative
PR- 100bpm
BP-100/70 mmhg ,RR-19 cpm
Spo2-98%on RA
CVS -S1S2 heard
RS-bilateral AE +
P/A- distended, nontender

Investigations :
1.ABG: Ph -7.46
PCo2-23.6
Po2 -110

Hco3-16.7
StHCo3-18.5
2.Na-124 ,k-5.2 , cl-92

Treatment:
1.same treatment continued
2 tranexa stopped
3.nebulisation asthalin 4 respules Stat
4.10 units of HAI in 25D Stat IV
5.inj pan 80mg stat
6.inj octreotide 50cc IV STAT
7 aspiration of ryles tube hourly and look for any blood
8.soap water enema

DAY3
pt passed twice on day2
O/E: pt is conscious,coherent ,cooperative

Constructional apraxia

Temp-afebrile to touch
PR- 120bpm
BP-110/70 mmhg ,RR-18cpm
Spo2-94%on RA
CVS -S1S2 heard
RS-bilateral AE +
P/A- distended, nontender
Bowel sounds +
Investigations:
1. Haemogram
Hb-3.6 gm/dl
Tlc-12,000 cells/cumm
Plt -80,000cells /cumm
2. PT -more than 1min
APTT- more than 1min
INR-3.5
3.RFT
Urea -81
Creat 1.1
Uric acid 4.3
Ca 9.6
Po4 - 3.7
4.electrolytes
Na-129
K- 4.8
Cl-97
5.GRBS -108 mg/dl
6.ABG
. Ph -7.49
PCo2-21.7
Po2 -109
StHCo3-18.9
Hco3 -16.4
7.ECG

Treatment: high protein diet (2eggs / day)
Oral fluids
1. Air or water bed
2. Fluid restriction <1.5litres/day
Salt restriction <2.4gms/day
3. Inj augmentin 1.2gm IV/BD
4. Inj pan 80 mg IV stat
Followed by injpan 40mg in 100NS @20ml/hr
5. Inj zofer 4mg IV/TID
6. Inj rifaximin 550mg /PO/BD
7. Inj vit k 10mg IV/OD
8. Syp lactulose 15ml/PO/TID
9. Tab udiliv 300mg/PO/BD
10.syp hepameiz 15 ml/PO/OD
11.Inj metrogyl 500mg IV/TID
12. Inj thiamine 100mg in 100mlNS /IV/TID
13.strict BP/PR/TEMP/Spo2 CHARTING 2nd HOURLY
14.strict I/O charting
15.GRBS 8th hourly
16.protein x powder 4tablespoons in glass of milk TID
17. 2 FFP 
18.inj lasik 20mg /iv /od
19.soap water enema if patient didnt pass stools 3times/day

20.asd done

DAY4
Patient passed stools 4 times on day3 and once on day 4
No fever spikes 

Complaints of swelling over left dorsum of foot 

O/E: pt is conscious,coherent ,cooperative

Constructional apraxia 

Temp-afebrile to touch
PR- 120bpm
BP-100/60 mmhg ,RR-18cpm
CVS -S1S2 heard
RS-bilateral AE +
P/A- distended, nontender
Bowel sounds +
Investigations:
1. Haemogram
Hb-3.1gm/dl
Tlc-10,9000 cells/cumm
Plt -1lakhcells/cumm
2. PT -more than 1min
APTT- more than 1min
3.LFT:
TB -5.47,DB- 2.10,ALP-150 ,
SGOT-34 ,SGPT -20
TP-4.6 , A/G-0.56

4.grbs -136mg/dl
5.CT-4min 30sec
BT-2min30sec
6.stool for occult blood - +
7.RFT-
Urea -77
Creat 1.1
Uric acid 4.4
Ca 9.2
Po4 - 2.9
8.electrolytes
Na-132
K- 4.6
Cl-98
9.ecg

10.swab ulcer for culture 

11.blood in syringe haematoma c/s

Treatment: high protein diet (2eggs / day)
Oral fluids 
1. Air or water bed 
2. Fluid restriction <1.5litres/day 
Salt restriction <2.4gms/day
3. Inj augmentin 1.2gm IV/BD
4. Inj pan 80 mg IV stat 
Followed by injpan 40mg in 100NS @20ml/hr
5. Inj zofer 4mg IV/TID
6. Tab rifaximin 550mg /PO/BD 
7. Inj vit k 10mg IV/OD
8. Syp lactulose 15ml/PO/TID 
9. Tab udiliv 300mg/PO/BD
10.syp hepameiz 15 ml/PO/OD
11.Inj metrogyl 100ml IV/TID
12. Inj thiamine 100mg in 100mlNS /IV/TID 
13.strict BP/PR/TEMP/Spo2 CHARTING 2nd HOURLY 
14.strict I/O charting 
15.GRBS 8th hourly
16.protein x powder 4tablespoons in glass of milk TID
17. 4FFP trasfused
18.inj lasik 20mg /iv /bd 
19.soap water enema if patient didnt pass stools 3times/day

20.asd done

21.aspirated the swelling and sent to c/s