A 56 years old Male Patient With Portal Hypertension

THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT 
CHEIF COMPLAINTS:-
C/O pain in abdomen since 4days.
Abdominal distension since 4days. 
Decreased urine output since 4days. 
HISTORY OF PRESENT ILLNESS :-
Patient was apparently asymptomatic 4days ago then he developed pain in abdomen (upper abdominal region).H/O distension of abdomen since 4days. 
No H/O fever, vomiting, nausea,constipation. 
H/O last alcohol intake 5days back. 
HISTORY OF PAST ILLNESS :-
No K/C/O Hypertension, Diabetes, coronary artery disease. 
TREATMENT HISTORY:-
No previous treatment history. 
PERSONAL HISTORY:-
Married
Appetite-normal 
Diet- Non veg
Bowels- regular 
Micturition- normal 
Known allergies- no
Habits- alcohol intake daily.
FAMILY HISTORY:-
no significant family history 
GENERAL EXAMINATION:-
no pallor, cyanosis, icterus, lymphadenopathy, clubbing of fingers or toes, Oedema of feet, malnutrition, dehydration. 
VITALS:-
Temp- 98.4 F
Pr- 102/ min
Rr-20/ min
Bp-120/90 mm /Hg
Spo2- 98%
GRBS- 94 mg%
SYSTEMIC EXAMINATION:-
a)CVS - S1 S2 Positive 
b)Respiratory system
No dysponea, wheeze. 
Position of trachea central. 
Breath sounds- vesicular
c)Abdomen
Shape of abdomen- distended. 
No Tenderness, palpable mass, no bruits.
Spleen and Liver-not palpable. 
d)CNS
    Level of consciousness- conscious 
    Speech- normal 
     Signs of meningeal irritation like neck           
      Stiffness, kerning 's sign- no
     Cranial system, motor system, sensory 
     system- normal.
     no cerebral signs
PROVISIONAL DIAGNOSIS:-
Pain in abdomen with decreased evaluation. 
INVESTIGATIONS:-
ECG
Serum amylase 
Serum lipase
peripheral blood smear 
Rbc- normocytic, normochromic
Wbc - decreased count 
Platelet count- decreased 
DIAGNOSIS:-
Decompensated liver disease with portal Hypertension  with pancytopenia
HBsAg -Positive 
Moderate Ascites 
Splenomeagly
B12 vitamin deficiency
TREATMENT:-
Fluid restriction <1lit/day
Salt restriction <2gm/day
Syp Lactulose 15ml PO
Tab. Rifagut 500mg
Tab. Lasilactone
Tab.Folic acid
Inj- vitcofol 1500mg OD
Inj- vitB12 1500mcg 


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