E log of p. Ruchithareddy

Hello everyone its me Ruchitha. I have joined in the medicine posting recently. Here Iam presenting  a case of I have followed 
CASE:
A Female patient who is daily labourer in occupation of age 55 years  walked in to casualty with the chief complaints of the distension of the abdomen since last 10 days. 
Present illness :She is apparently asymptomatic 2 years back, when she first developed pain in abdomen which was dull aching type, which was localized to the epigastrium and left hypochondrium pain was insidious in onset and it got aggravated with food intake pain used get relieved through self induced vomiting. She also stated that she is having early satiety and started lossing her weight. Which she first observed that her clothes becoming loose ( thickness in the lips and temporal wasting). She also stated that she is progressively becoming fatigued such that she has to finally stop going to her work .she also complained that once she had a involuntary vomiting which  was frank blood ( hematemesis) .It was only one episode which was 50 ml. No h/o of bilious vomiting,heart burn, nocturnal cough, dyspepsia, Malena, hematochezia, purpura, echymosis, loose stools, or constipation. She also complained that she was having night sweats which were drenching and made her bath. She is having low grade fever, chills and rigors. She denies joint pain, back pain, dysuria, hematuria, cough, expectorations, wheeze (or) frequent URTIS. 
Past history :She is a. Not a known case of diabetes,, hypertension, tuberculosis, asthma, epilepsy. 
Family history :She is a mother of three children. Her husband died at the age 42 with respiratory causes.
 Medical history:She underwent hysterectomy for fibroids. 
Personal history :
Appetite :Decreased 
Diet:mixed
Sleep :Adequate 
Bowel and bladder :Regular 
Not a known case of alcoholic and smoker
General examination :patient was conscious, coherent, cooperative. 
Thin built and moderately nourished 
P. R: 72bpm 
B. P:140/80
Temperature : afebrile 
Respiratory rate :18 cpm
Grbs :140mg/dl
Pso2:98%
Systemic examination :
CVS : s1 ,s2 were heared. No murmurs. No additional sounds were heared. 
Respi: trachea is central in position
Bilateral air entry is present 
Vesicular breath sounds were heared 
CVS:no neurological abnormalities were detected 
Per abdomen :
Patient was exposed from xiphisternum to pubic symphysis .patient was examined in supine and standing position 
Inspection :Abdomen is distended 
Linea nigra is present 
No scars or draining sinuses were present 
No engorged veins
Palpation : Temperature is afebrile 
Tenderness present in the epigastrium and left hypochondrial region .Grith of the abdomen was 85cm
Palpable mass felt in the left hypochondrial region .
Moderate splenomeagaly is present of 16cm. 
Fluid thrill is absent 
Percussion :Shifting dullness is present . Flank fullness is present 
Auscultation :Bowel sounds were heared 
Investigation :
ECG:

X ray :

Hemogram :
CUE:
RFT:
LFT:
Serology 
APTT
PT
Lipid profile 
Thyroid profile 
Esr and CRP



USG


CE CT:
,


Impression :
Portal vein thrombosis 
Moderate splenomeagaly 
Moderate ascitis
Caudate lobe hypertrophy 
Left lobe little shrunken 
Oseophageal varices 
Abdominal collaterals 
Ascitic tap :

Endoscopy :
Grade 4 oseophageal varices 
Treatment :
Tab"LASILACTONE 20/50/po/BD
Tab CARVEDALOL3 125 mg/po/BD
Tab NORFLOX 400 mg/po/BD
Tab PANTOP 40 mg/po/BD
Tab NUEROBION FORTE PO/OD
Tab OROFER PO/BD
Tab FOLATE 5mg/po/OD
Syrup zincovit 10 mg/po/HS
SAlt and fluid restriction
OnGastrroenterologistadvised
anticoagulant therapy 
Oesophageal varices band ligation
Porto systemic shunt surgery 

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