28yr old female

 25/10/21.

 Currently in AMC. Today's OPD admission.

A 28 year old woman, housewife by occupation presented to the opd with the complaints of
Abdominal distension since 5 days

Patient was born out of a second degree consanguineous marriage. Her father was also born out of a second degree consanguineous marriage. She has 2 elder sisters. 

At 4 to 5 years of age she had jaundice for which she was given ayurvedic medications. She had recurrent episodes of jaundice for 3 years for which she kept consuming Ayurveda medications. She also experienced high coloured urine back then.

She studied till her inter second year. She attained menarche at the age of 15 years. She gets regular menstrual cycles every 30 days lasting for 3 days. She changes around 2 to 3 pads per day.

She got married in November 2020. It was a second degree consanguineous marriage. 


In January 2021 - she experienced increased frequency of urine for which the patient visited a hospital where
her RBS was 500mg/dl. She was even found to have pancytopenia - her Hb was 6.9 g/dl, TLC - 3000/cumm, Platelets- 69,000 cells/cumm. 
They were advised admission but the patient wasn't willing. 1 PRBC transfusion was done.

In January she was found out to be pregnant.

In February - She developed rashes on her bilateral upper limbs and lower limbs.
She had an abortion in February during her second month of gestation.

She also started experiencing multiple joint pains involving bilateral MCP, PIP along with swelling and morning stiffness.
ANA profile was sent.

She was started onTab Wysolone 5mg OD, Tab Naproxen 500mg OD.

Tab wysolone was increased to 10mg OD and Hydroxychloroquine 200mg OD was started.

Also during her pregnancy she was started on inj Human Insulin mixtard 22 units morning and 16 units at night

In August- Her ANA profile was again repeated and it came positive for cardiolipin and beta 2 glycoprotein antibodies came positive.
She continued using Tab Wysolone 20mg OD

Since 5 days she has been complaining of Abdominal distension since 5 days which has progressed. Not associated with dyspnea, reduced urine output, pedal edema. 
She also tells that she has  lost weight over the past 2 months. 

On examination - 
She is a thin built woman with pallor
PR - 87 bpm
Bp - 90/70 in left arm 
110/60 in right arm 
Respiratory Rate- 18 cpm 
Spo2 - maintaining 98% on Room air 
Temp - 98.6 F
Grbs - 387 mg/dl
Per Abdomen -
Distended
Umbilicus everted
Shifting dullness +
Bowel sounds +
You can also notice plaster after ascitic tap 
Cvs- 

Pulse Right Left

Carotid ++ ++
Brachial ++ +
Radial ++ -
Femoral ++ ++
Posterior tibial + -
Dorsalis pedis - -

S1,S2 +

Lungs - BAE +
Clear
 
Cns - NAD

DIAGNOSIS: 
Chronic liver disease 
Hyperglycemia - known case Type 1 DM
? APLA

TREATMENT: 11AM
1. fluid restriction <1L/day
2.salt restriction<2gm/day
3.Tab.LASILACTONE (20/50mg)/po/BD
   8AM -4PM
4.Tab. WYSOLONE 20mg/OD
   8AM
5.Tab.Pantop 40mg po/OD
   8AM
6.INJ. HUMAN INSULIN MIXTARD
   22units mrng 8 AM
   16units night 8PM
7.GRBS charging 6th hourly
   8AM - 2 PM- 8PM- 2AM.
8.Daily abdominal girth measurement and weight.
9. Monitor vitals.


Hemogram -
Hb - 8.3 g/dl
TLC - 4000 cells/cumm
Platelet - 1 L/cumm

Cue shows sugar +++

LFT - 
Tb - 1.17
Db - 0.39
Ast -28
Alt - 35
Alp - 434
Albumin - 2.9
TP - 5.4






SEROLOGY: NEGATIVE




SOAP NOTES DAY 2 

AMC  BED 5

S:
-C/O Abdominal distension
-S/P Ascitic tap done yesterday around 500ml
- did not pass stools yesterday.

O:
-pt is C/C/C
- Afebrile
-No pedal edema
-BP-100/60mmhg
-PR-82BPM
CVS: S1S2 heard
RS: BAE +, NVBS 
P/A: Distended
         Shifting dullness+
        B.S +
        Splenomegaly+
Engorged veins:no

ASCITIC FLUID ANALYSIS:

High SAAG-low protein.
SAAG: 2.14 
Ascitic protein:1.0
Sugar:472
Amylase:38
LDH: 148.
Sr.LDH-220.

GRBS: 206MG%
 Wt:36kgs
Abd girth- 76cms

A:

- CLD secondary to
 BUDD CHIARI SYNDROME.
-with K/C/O TYPE 1 DM with
UNCONTROLLED SUGARS.
- with H/O ? APLA.
-? SUB CLINICAL HYPOTHYROIDISM.

P:

1. Fluid restriction<1.5 lit/day
2.salt restriction: <2gm/day
3.T.LASILACTONE 20/50mg /po/OD.
4.T.WYSOLONE 20MG /PO/OD.
5.T.PANTOP 40MG PO/OD
6.INJ. HAI 40IU in 39ml NS @ 6ml/hr.
7. NBM till further orders.
8.GRBS hourly
9.strict I/O charting.
10.BP/PR/TEMP charting.






Review 2DECHO


GLYCATED HEMOGLOBIN HBA1C: 6.9


SOAP NOTES  DAY 3

AMC BED 5

Case seen by : 

Dr.Sai Surya(intern )
Dr.Neha (intern )
Dr.Trishaala(intern )
Dr.Varaprasad(intern )
Dr.Srivalli(intern )
Dr.Harika.K (intern )
Dr.Aashitha PG Y 3
Dr.Nikitha PG Y3
Dr.Usha PG Y 3
Dr.Shashikala PG Y3
Dr.Hareen Sr Resident 
Dr.Arjun kumar Ass prof
Dr .Rakesh Biswas HOD

S:

C/O Abdominal distension
No fresh complaints.

O:

Pt is C/C/C
TEMP: 97.6°f
BP: 100/60mmhg
PR:89bpm regular,normal volume
RR:20CPM
CVS: S1S2 +, no murmers.
RS: NVBS + ,no crepts.
P/A: Distended
        B.S +
GRBS: 187 '100'
I/O: 1000/850ML
SPO2: 98% @RA

SPLENOMEGALY +
SHIFTING DULLNESS+
PASSED STOOLS +
NO ENGORGED VEINS
WEIGHT: 37KGS
ABD GIRTH-81CMS.

FASTING BLOOD SUGAR: 119MG%

SERUM ELECTROLYTES: 

NA: 140
K: 3.7
CL: 104

SERUM OSMOLALITY: 300

HB1AC: 6.9

A:

CLD secondary to
 BUDD CHIARI SYNDROME.
-with K/C/O TYPE 1 DM with
UNCONTROLLED SUGARS.
- with H/O ? APLA.
-? SUB CLINICAL HYPOTHYROIDISM

P:

1.Fluid restriction<1.5 lit/day
2.salt restriction: <2gm/day
3.T.LASILACTONE 20/50mg /po/BD.
4.T.WYSOLONE 20MG /PO/OD.
5.INJ. HAI S/C PRE MEAL ACCORDING TO SLIDING SCALE.
6.Wt and Abd girth- daily
7.strict I/O charting.
8.BP/PR/TEMP/GRBS charting.

SERUM IGg antibodies sample sent.

28/10/21

SOAP NOTES DAY 4

AMC BED 5.

Case seen by : 

Dr.Sai Surya(intern )
Dr.Neha (intern )
Dr.Trishaala(intern )
Dr.Varaprasad(intern )
Dr.Srivalli(intern )
Dr.Harika.K (intern )
Dr.Aashitha PG Y 3
Dr.Nikitha PG Y3
Dr.Usha PG Y 3
Dr.Shashikala PG Y3
Dr.Hareen Sr Resident 
Dr.Arjun kumar Ass prof
Dr .Rakesh Biswas HOD

S:

C/O Abdominal distension
No fresh complaints.

O:

Pt is C/C/C
AFEBRILE
BP: 100/60mmhg
PR:82bpm regular,normal volume
RR:20CPM
CVS: S1S2 +, no murmers.
RS: NVBS + ,no crepts.
P/A: Distended
        B.S +
GRBS: 420MG% 16U
I/O: 700/1050ML
SPO2: 98% @RA

SPLENOMEGALY +
SHIFTING DULLNESS+
PASSED STOOLS +
NO ENGORGED VEINS
WEIGHT: 35KGS
ABD GIRTH-75CMS.

ASCITIC TAP DONE YESTERDAY.


A:

CLD secondary to CIRRHOSIS
-with K/C/O TYPE 1 DM with
UNCONTROLLED SUGARS.
- with H/O ? APLA.
-? SUB CLINICAL HYPOTHYROIDISM

P:

1.Fluid restriction<1.5 lit/day
2.salt restriction: <2gm/day
3.T.LASILACTONE 20/50mg /po/BD.
4.T.WYSOLONE 20MG /PO/OD.
5.INJ. HAI S/C PRE MEAL
8AM - 2PM - 8PM
6.Wt and Abd girth- daily
7.strict I/O charting.
8.BP/PR/TEMP 4TH HRLY.
9. GRBS - 7 o PROFILE
8AM -10AM
2PM-4PM
8PM-10PM
10. TAB . RIFAMIXIN 550MG /PO/BD.


2PM-3PM-4PM


SERUM ELECTROLYTES:
Na- 139
K- 3.8
Cl-99



SOAP NOTES DAY 5

AMC BED 5

Case seen by : 

Dr.Sai Surya(intern )
Dr.Neha (intern )
Dr.Trishaala(intern )
Dr.Varaprasad(intern )
Dr.Srivalli(intern )
Dr.Harika.K (intern )
Dr.Aashitha PG Y 3
Dr.Nikitha PG Y3
Dr.Usha PG Y 3
Dr.Shashikala PG Y3
Dr.Hareen Sr Resident 
Dr.Arjun kumar Ass prof
Dr .Rakesh Biswas HOD

S:

no fresh complaints.

O:

Pt is C/C/C
Afebrile
BP: 110/70mmhg
PR:86bpm regular,normal volume
RR:18CPM
CVS: S1S2 +, no murmers.
RS: NVBS + ,no crepts.
P/A: Distended
SHIFTING DULLNESS+
        B.S +
GRBS: 237MG%
I/O: 700/1050ML
SPO2: 98% @RA

SPLENOMEGALY+
DIDNT PASS STOOLS 
NO ENGORGED VEINS
WEIGHT: 34KGS
ABD GIRTH-72cms

A:

CLD secondary to CIRRHOSIS
-with K/C/O TYPE 1 DM with
UNCONTROLLED SUGARS.
- with H/O ? APLA.
-? SUB CLINICAL HYPOTHYROIDISM

P:

1.Fluid restriction<1.5 lit/day
2.salt restriction: <2gm/day
3.T.LASILACTONE 20/50mg /po/BD.
4.T.WYSOLONE 20MG /PO/OD.
5.INJ. HAI S/C PRE MEAL 
  8AM NPH - HAI - NPH
          15 - NPH - 15
           10- 10 - 10} HAI
6.TAB.RIFAXIMIN 550MG /PO/BD
7.Wt and Abd girth- daily
8.strict I/O charting.
9.BP/PR/TEMP charting.
10.GRBS 7 0 PROFILE MONITORING
 8AM - 2PM - 8PM - 2AM
10AM 4PM 10PM 



30/10/21
SOAP NOTES DAY 6

SHIFTED TO WARD.

Case seen by : 

Dr.Sai Surya(intern )
Dr.Neha (intern )
Dr.Trishaala(intern )
Dr.Varaprasad(intern )
Dr.Srivalli(intern )
Dr.Harika.K (intern )
Dr.Aashitha PG Y 3
Dr.Nikitha PG Y3
Dr.Usha PG Y 3
Dr.Shashikala PG Y3
Dr.Hareen Sr Resident 
Dr.Arjun kumar Ass prof
Dr .Rakesh Biswas HOD

S:
NO FRESH COMPLAINTS.

O:
Pt is C/C/C
Afebrile
BP: 110/70mmhg
PR:82bpm regular,normal volume
RR:16CPM
CVS: S1S2 +, no murmers.
RS: NVBS + ,no crepts.
P/A: Distended
SHIFTING DULLNESS+
        B.S +
GRBS: 258MG%
I/O: 600/1250ML
SPO2: 98% @RA

SPLENOMEGALY+
PASSED STOOLS 
NO ENGORGED VEINS
WEIGHT: 34.6KGS
ABD GIRTH-70cms

A:

CLD secondary to CIRRHOSIS
-with K/C/O TYPE 1 DM with
UNCONTROLLED SUGARS.
- with H/O ? APLA.
-? SUB CLINICAL HYPOTHYROIDISM

P:

1.Fluid restriction<1.5 lit/day
2.salt restriction: <2gm/day
3.T.LASILACTONE 20/50mg /po/BD.
4.T.WYSOLONE 5MG /PO/OD.
5.INJ. HAI S/C PRE MEAL 
  8AM NPH - HAI - NPH
          15.       12.      15
          12.                   12
6.TAB.RIFAXIMIN 550MG /PO/BD
7.Wt and Abd girth- daily
8.strict I/O charting.
9.BP/PR/TEMP/GRBS charting.




















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