Cirrhosis

1. CASE PRESENTATION

2. A female patient of age 55yrs was admitted in the hospital
with the following complaints:
Generalized weakness-3 days
Loss of appetite
Numbness in both feet
ON EXAMINATION :
Patient normal & conscious
BP : 120/80(mmHg)
PR : 84 BPM
RR : 22 /min
Abdominal-soft
CVS - s1s2+
Lungs – BAE+
Pain in mouth

3. PHYSICAL EXAMINATION:
D1 D2 D3
BP(mmHg) 120/80 120/80 130/80
PR(BPM) 84 80 86
RR(CPM) 20 24 22
Temp 98.6 98.6 98.6

4. SOCIAL HISTORY:
Regular alcoholic - since childhood
Tobacco user.
SURGICAL HISTORY :
TUBECTOMY
PSYCOLOGICAL STATUS :
Nervous
Decreased sleep

5. LABORATORY INVESTIGATIONS:
PARAMETERS NORMAL RANGE OBSERVED RANGE
** SODIUM 135-145mmol/lit 130mmol/lit
** Hb 13-17gm% 8.6gm%
** POTTASIUM 3.5-5.5mol/lit 2.6 mmol/lit
** CHLORIDE 98-108mmol/lit 87mmol/lit
**ALP 30-120IU/L 243IU/L
**TB 1.0mg/dl 8.1mg/dl
** DB 0.6mg/dl 6.8mg/dl
Continued………..

6. PARAMETERS NORMAL RANGE OBSERVED RANGE
** ALT/SGPT upto 40 IU/L 126IU/L
** AST/SGOT upto 42 IU/L 134IU/L
** Albumin 3.5-5 gm/dl 2.7gm/dl
** Total protein 6.5-8.5gm/dl 6.1gm/dl
CREATININE 0.6-1.1mg/dl 0.51mg/dl
UREA 15-40mg/dl 25mg/dl
BUN 7-20mg/dl 5.7mg/dl

7. • OTHER INVESTIGATIONS :
USG – ABDOMEN :
Hepatomegaly & Marked
Diffuse Hepatic-Steatosis & Heterogenous
Appearance Of Pancreas Suspicious For
Pancreatitis

8. DIAGNOSIS
• ALCOHOLIC LIVER DISEASE
LIVER CIRRHOSIS

9. SOAP NOTE
SUBJECTIVE:
Generalized weakness – 3days
Loss of appetite
Numbness in both feet.
OBJECTIVE:
Patient was normal and Conscious
Sodium, potassium , chloride , Hb, Total proteins,
Albumin – Decreased
ALP,SGOT,SGPT,BILIRUBIN - Increased

10. DRUG NAME GENERIC NAME DOSE FREQUENCY D1 D2 D3
INJ.MONOCEF ceftriaxone 1gm BD Y - -
INJ.FLAGYL metronidazole 400 mg BD - Y Y
T.PAN pantoprazole 40mg OD Y Y Y
T.UDILIV Ursodeoxycholic
acid
300mg TID Y Y Y
INJ.ZOFER ondansetron 4mg BD Y Y Y
T.LIBRIUM chlordiazepoxide 25mg OD Y Y Y
INJ.THIAMINE Vit supplement 1OOmg OD Y Y Y
DRUG CHART:

11. PHARMACOLOGICAL PLAN :
T.MONOCEF – 200m- BD
T.UDILIV FORTE – 300mg – BD
T.LIBRIUM – 25mg – OD
T.THIAMINE – 100mg – OD
OINT. ZYTEE GEL – TID
RESOURCE HEPATIC POWDER.

12. PLAN:
NON-PHARMACOLOGICAL PLAN:
Avoid alcohol and tobacco intake
Alcohol Rehabilitation programme or counselling
programme should be conducted.
Minimal intake of salt
patient is malnourished so high calorie food should be
given.
Avoid intake of shellfish & raw seafood.
Before taking any medicine like acetaminophen etc.,
seek advice from your doctor .
Adequate quantity of water & fruits& are taken.