General Medicine e-log

A case of 31 yr old male with CLD and PORTAL HYPERTENSION.

Hiii, I am A.Roopa Sri,3rd semester student. 

This is an online E log book 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 series of inputs from available global online community of experts with an aim to solve those patient's clinical problems w8ith collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio.

Q¹¹¹1¹

Yellowish discolouration of sclera since 4 days

Indigestion and tightness of abdomen since 4 days

Pt was apparently asymptomatic 2 yrs back,then he developed pain abdomen for which he went to hospital and diagnosed with fatty liver relieved with medication

1 yr back pt developed pedal edema,jaundice and abdominal tightness and anasarca 3 times in a year for which he underwent paracentesis 3 times

H/o jaundice 4 to 5 times in a span of 2 yrs

H/o hemetemesis 4 to 5 times per day

H/0 malena

2 months back 1 episode/ day hemetemesis 

For which he admitted in NIMS for 1 week and discharged

Pt developed hypopigmented lesions over both upper limbs and back and itching was their,4 months back then he using ointmemt for that

Not a k/c/o Dm ,HTN ,Asthma,TB,CVD

ALCOHOLIC-180ml / day since 10 yrs

General examination 

Pt was conscious coherent cooperative

No pallor cyanosis clubbing lymphadenopathy and edema 

Icterus+

Temp: 98.2F

BP: 110/80   mmHg

PR: 104 bpm

RS:20 cpm

GRBS: 152 mg/dl

CVS: s1s2+

Rs: BAE+

P/A  soft non tender

Distended abdomen

Clinical images

Aphrexia chatting 

Ecg

chest x ray

USG

1)Hepatomegaly with altered echotexture of liver

2)Chronic thrombosis of extrahepatic portion of portal vein with portal recanalisation

3)Multiple periportal ,perisplenic,peripancreatic collaterals noted

2D ECHO

EF 62 %

No RWMA,good LV  systolic function

No diastolic dysfunction

Hemogram

HB: 7.3

TLC :9600

PLT: 1.97 lakhs

PT :18 secs

INR: 1.33

ApTT 35 sec 

BGT AB +ve

RBS 108

B urea 12

Creat 0.7 

LFT ON 29/5/22

CUE

Provisional diagnosis

CHRONIC LIVER DISEASE WITH PORTAL HYPERTENSION with NORMOCHROMIC NORMOCTYTIC ANEMIA WITH HYPOALBUMINEMIA ? TINEA

TREATMENT

1)TAB  LASIX 40 mg/BD

2)TAB ALDACTONE 50 mg /BD

3)TAB UDILIV 300 mg po /BD

4)Syrp LACTULOSE 20 ml po /TID

The patient discharged on 22nd of June 2022.

What is the anatomical location of patient problem?

Portal hypertension is high blood pressure in the portal vein. The portal vein is located in your belly (abdomen). It gets blood from your digestive organs (large and small intestines, stomach, pancreas, spleen) and carries it to the liver. The liver cleans and filters waste from the blood.our body carries blood to your liver through a large blood vessel called the portal vein. Cirrhosis slows your blood flow and puts stress on the portal vein. This causes high blood pressure known as portal hypertension.As a result, high pressure in the portal system develops. This increased pressure in the portal vein may lead to the development of large, swollen veins (varices) within the esophagus, stomach, rectum, or umbilical area (belly button).

Risk Factors

• Cirrhosis (liver scarring), which can be caused by: History of alcohol use. Hepatitis B or C infection. Long term inflammation of the liver. Hemochromatosis, or iron overload.
• Congestive heart failure.
• Arteriovenous malformations (AVMs)
• Hypercoagulable states.
• Blood borne viruses
• Obesity.
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