45 year old with seizures secondary to hepatic encephalopathy with alcoholic hepatitis and thrombocytopenia

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Unit II admission on 21/02/2021
DR. JAYANTH ( INTERN)
DR. AMULYA ( INTERN)
DR. SURYA PRADEEP ( INTERN)
DR. ASHA KIRAN ( INTERN)
DR. YAMINI ( INTERN)
DR. VAMSHI ( INTERN)
DR. ISMAIL  (INTERN)
DR. PRADEEP ( PG 1st YEAR)
DR. NIKITHA ( PG 2nd YEAR)
DR. SUFIYA ( PG 3rd YEAR)
DR. SATISH ( PG 3rd YEAR)
Faculty : DR. VIJAYALAXMI

Here is a case i have seen: 

Patient came to casualty with complaints of Loss of appetite since 2 days
Vomitings 2 episodes in morning
Involuntary movements of upperlimbs (2episodes).

45yr male Xerox shop owner who is a chronic alcoholic takes 180ml/day with only one meal per day was apparently alright till 20days back.
Today morning while having food he had nausea and vomiting. In the afternoon, he had another episode of vomiting, non projectile, non bilious, contains food particles,non foul smelling.

At around 5:30pm while he was sitting in a chair had involuntary movements of upperlimb(seen by neighbours) lasted for 1-2 mins. After 30mins he had another episode of involuntsry movements of upperlimb , associated with tongue bite lasted for 1-2 mins

No involuntary defecation or micturition.

Not a k/c/o DM2,HTN,Asthma,TB,CAD

K/c/o epilepsy ( 10yrs back he had multiple episodes, on irregular medication
Recently 6months back had 2episodes of seizures)

Patient is chronic alcoholic having 180ml/day whisky since 20yrs

O/E:
Patient c/c/c
Icterus present 


No signs of pallor, clubbing, lymphadenopathy, cyanosis, pedal edema.
BP-110/70mmHg
RR-17cpm
PR-98bpm
SPO2-98% @room air
GRBS- 165 mg/dl
CVS- s1 s2+
RS- BAE+
P/A- Soft, non tender,BS+
CNS- NFD HMF intact. 




INVESTIGATIONS-
HbSAg, HIV1/2, HCV- Non reactive
Dengue NS1, IgM, IgG- Negative




Diagnosis:
Seizures  under evaluation (? focal seizures)
Secondary to ?hepatic encephalopathy with thrombocytopenia

Treatment: on day of admission 21/02/2021
IVF 1unit NS and 1 unit RL@30ml/he
Avoid protein rich diet
Inj.Thiamine 1Amp in 100ml NS IV TID
Inj.Lorazepam 2cc IV SOS
Ointment lignocaine for tongue bite
Vitals charting 4th hrly
I/O charting
Inj.Optineuron 1Amp in 100ml NS IV OD
Syp.Lactulose 15ml PO BD

Investigation-
PT 20, INR 1.45, APTT 39.

TREATMENT ON DAY 1 (22/02/2021)
S-
Patient passed stools and vomitings decreased.
O-
Patient is c/c.
Afebrile
BP-120/80mmhg
PR-104bpm
CVS-S1S2 present
CNS- NFD, HMF intact.
RS- BAE present.
PA- Soft NT.
A-
Seizures  under evaluation Secondary to ?hepatic encephalopathy with alcoholic hepatitis with thrombocytopenia.
PSYCHIATRY referral was taken i/v/o alcohol withdrawal-

P-
1. IVF NS RL U. O + 30ml/hr.
2. Inj. THIAMINE 1amp in 100ml NS IV TID.
3. Inj.  LORAZEPAM 2cc IV SOS.
4. Inj. OPTINEURON 1amp in 100ml NS IV OD at 2pm.
5. Inj. VIT K 10mg slow IV OD.
6. T. UDILIV 300mg PO BD.
7. T. RIFAGUT 550mg PO BD.
8. Syp. LACTULOSE 15Ml PO BD.
9. Syp. HEPAMERZ 15ml PO OD.
10. Avoid protein rich diet.
11. Oint.  LIGNOCAINE L/A for tongue bite.
12. BP PR TEMP GRBS monitoring 4th hrly.
13. I/O charting.
14. T. OXAZEPAM 30mg.
15. T. LARINATE KIT.

TREATMENT ON DAY 2 (23/02/2021)

S-
Patient had irrelevant talk for 30min at 4:00am.
O-
Patient is c/c.
Afebrile
BP-120/80mmhg
PR-97bpm
CVS-S1S2 present
CNS- NFD, HMF intact.
RS- BAE present.
PA- Soft NT.
A-
Seizures  under evaluation Secondary to ?hepatic encephalopathy with alcoholic hepatitis with thrombocytopenia with delirium.
P-
1. IVF NS RL U. O + 30ml/hr.
2. Inj. THIAMINE 1amp in 100ml NS IV TID.
3. T. OLANZEPINE 2.5mg PO BD.
4. Inj.  Aoptineuron 1amp in 100ml NS IV OD at 2pm.
5. Inj. VIT K 10mg slow IV OD.
6. T. UDILIV 300mg PO BD.
7. T. RIFAGUT 550mg PO BD.
8. Syp. LACTULOSE 15Ml PO BD.
9. Syp. HEPAMERZ 15ml PO OD.
10. Avoid protein rich diet.
11. Oint.  LIGNOCAINE L/A for tongue bite.
12. BP PR TEMP GRBS monitoring 4th hrly.
13. I/O charting.
14. T. OXAZEPAM 30mg.
15. T. LARINATE KIT.
16. Inj. HALOPERIDOL 5mg IM SOS after informing PG.
17. Condom catheterisation.
18. Ryles catheterisation done.
19. Two units of FFP transfusion done.
Transfusion was uneventful.

INVESTIGATIONS- 



 TREATMENT ON DAY 3 (24/02/2021)

S-
Patient is concious and talking irrelevant.
Not passed stools.
O-
Patient is c/c.
Afebrile
BP-130/80mmhg
PR-104bpm
CVS-S1S2 present
CNS- E3V4M6= 13/15
RS- BAE present.
PA- Soft, distended(83cms)
A-
Delirium secondary to alcoholic withdrawal with hepatic encephalopathy grade II with alcoholic hepatitis with thrombocytopenia.
P-
1. IVF NS RL U. O + 30ml/hr.
2. Inj. THIAMINE 1amp in 100ml NS IV TID.
3. T. OLANZEPINE 2.5mg PO BD.
4. Inj.  Aoptineuron 1amp in 100ml NS IV OD at 2pm.
5. Inj. VIT K 10mg slow IV OD.
6. T. UDILIV 300mg PO BD.
7. T. RIFAGUT 550mg PO BD.
8. Syp. LACTULOSE 15Ml PO BD.
9. Syp. HEPAMERZ 15ml PO OD.
10. Avoid protein rich diet.
11. Oint.  LIGNOCAINE L/A for tongue bite.
12. BP PR TEMP GRBS monitoring 4th hrly.
13. I/O charting.
14. T. OXAZEPAM 30mg.
15. T. LARINATE KIT.
16. Inj. HALOPERIDOL 5mg IM SOS after informing PG.
17. Condom catheterisation.
18. Ryles catheterisation done.
19. Inj.  PANTOP 40mg IV OD.
20. Inj. CEFOTAXIME 1gm IV BD.
21. Tepid sponging.
22. Two units of FFP transfusion done i/v/o PT=20sec, APTT=39sec, INR=1.45
Transfusion was uneventful.


INVESTIGATIONS-
BT 2min, CT 5min, PT 19sec, INR 1.4,
APTT 37sec. 


TREATMENT ON DAY 4 (25/02/2021)
S-
C/o high grade fever spikes, passing 4 episodes of loose stools.
O-
Patient is c/c.
febrile to touch.
BP-140/80mmhg
PR-128bpm
Spo2-93% on RA.
CVS-S1S2 present
CNS- oriented to person only.
RS- BAE present.
PA- Soft, distended(83cms)
A-
Delirium secondary to alcoholic withdrawal (hyperactive) with hepatic encephalopathy grade II with alcoholic hepatitis with thrombocytopenia (resolving).
P-
1. IVF NS RL U. O + 30ml/hr.
2. Inj. THIAMINE 1amp in 100ml NS IV TID.
3. RT feed 50ml water hrly, 100ml milk 2nd hrly.
4. Inj.  OPTINEURON 1amp in 100ml NS IV OD at 2pm.
5. Inj. VIT K 10mg slow IV OD.
6. T. UDILIV 300mg PO RT BD.
7. T. RIFAGUT 550mg PO RT BD.
8. Syp. LACTULOSE 15Ml PO BD.
9. Syp. HEPAMERZ 15ml PO RT OD.
10. Avoid protein rich diet.
11. Oint.  LIGNOCAINE L/A for tongue bite.
12. BP PR TEMP GRBS monitoring 6th hrly.
13. I/O charting.
14. T. OXCARBAMAZEPINE 50mg BD.
15. Inj. HALOPERIDOL 2.5mg BD.
16. Inj.  PANTOP 40mg IV OD.
17. Inj. CEFOTAXIME 1gm IV BD.
18. Tepid sponging.
19. T. LARINATE KIT.

REVIEW USG-

PT 15sec, INR 1.11, APTT 30


 TREATMENT ON DAY 5 (26/02/2021)
S-
Patient sensorium improved, stools passed twice.
O-
Patient is c/c.
febrile to touch.
BP-120/80mmhg
PR-102bpm
CVS-S1S2 present
CNS- oriented to person only.
RS- BAE present.
PA- Soft, distended(84cms)
A-
Alcoholic hepatitis with thrombocytopenia with delirium(resolving) with cholelithiasis with cholecystitis(?CBD Obstruction) with jaundice ?Obstructive jaundice.
P-
1. IVF NS RL U. O + 75ml/hr.
2. Inj. THIAMINE 1amp in 100ml NS IV TID.
3. RT feed 50ml water hrly, 100ml milk 2nd hrly.
4. Inj.  OPTINEURON 1amp in 100ml NS IV TID.
5. Inj. VIT K 10mg slow IV OD.
6. T. UDILIV 300mg PO RT BD.
7. T. RIFAGUT 550mg PO RT BD.
8. Syp. LACTULOSE 15Ml PO BD.
9. Syp. HEPAMERZ 15ml PO RT OD.
10. Avoid protein rich diet.
11. Oint.  LIGNOCAINE L/A for tongue bite.
12. BP PR TEMP GRBS monitoring 6th hrly.
13. I/O charting.
14. Inj. HALOPERIDOL 2.5mg in 100ml NS IV.
15. Inj.  PANTOP 40mg IV OD.
16. Inj. CEFOTAXIME 1gm IV BD.
17. Tepid sponging.
18. T. OXETAL 150mg BD.
19. Inj.  ARTESUNATE 120mg IV STAT.
       0--------12---------24.


 PT-15sec, INR-1.1, APTT-30sec

Sr. Creatinine-0.9

TREATMENT on day 6 (27/02/2021)
S-
Patient c/o continuous  high grade fever  and pain at cannula site. 
O-
Patient is c/c.
febrile to touch-102F
BP-100/60mmhg 
PR-70bpm 
CVS-S1S2 present 
CNS- oriented to person only. 
RS- BAE present. 
PA- Soft, distended(85cms)
I/O=1400/1050
GRBS-124mg%
A- 
Delirium(resolved) secondary to ?alcohol withdrawal and ?hepatic encephalopathy with alcoholic hepatitis with cholelithiasis with cholecystitis and ?obstructive jaundice. 
P-
1. IVF NS RL U. O + 75ml/hr.
2. Inj. THIAMINE 1amp in 100ml NS IV TID. 
3. RT feed 50ml water hrly, 100ml milk 2nd hrly. 
4. Inj.  OPTINEURON 1amp in 100ml NS IV TID. 
5. Inj. VIT K 10mg slow IV OD. 
6. T. UDILIV 300mg PO RT BD. 
7. T. RIFAGUT 550mg PO RT BD. 
8. Syp. LACTULOSE 15Ml PO BD. 
9. Syp. HEPAMERZ 15ml PO RT OD. 
10. Avoid protein rich diet. 
11. Oint.  LIGNOCAINE L/A for tongue bite. 
12. BP PR TEMP GRBS monitoring 6th hrly. 
13. I/O charting. 
14. Inj. HALOPERIDOL 2.5mg in 100ml NS IV OD at 9pm.
15. Inj.  PANTOP 40mg IV OD. 
16. Inj. CEFOTAXIME 1gm IV BD. 
17. Tepid sponging. 
18. T. OXETAL 150mg BD. 
19. Inj.  ARTESUNATE 120mg IV 24hr dose. 
20. Abdominal girth monitoring. 
      
TREATMENT on day 7 (28/02/2021)

S-  
Sensorium improved,Passed stools

O-
 -  PATIENT IS CONCIOIOUS,  COHERENT AND COOPERATIVE  ORIENTED TO TIME PLACE AND PERSON  
AFEBRILE, 
BP -11O/80 MMHG
PR - 90 BPM
CVS - S1 S2 HEARD 
RR- BAE + NVBS 
P/A - SOFT,  NON TENDER 
CNS - NO FOCAL NEUROLOGICAL deficits
I/0-1400ml/1250ml
Blood culture-No growth
Urine culture-E coli >10*5cfu/ml 

A - 
DELIRIUM  RESOLVED   SECONDARY  TO ? ALCOHOLIC WITHDRAWAL  ,? HEPATIC ENCEPHALOPATHY 
WITH  ALCOHOLIC HEPATITIS 
WITH  CHOLECYSTITIS,  CHOLELITHIASIS
WITH ? OBSTRUCTIVE  JAUNDICE  
?UTI


P-
1.TAB OFLOXACIN 200 MG XBD  ( 8 AM----- X ------- 8 PM ) 
2.(Ivf  NS ,RL, DNS ) @ 100ML / HR 
3.INJ THIAMINE  1 AMP   IN 100 ML NS /  IV /TID 
4.INJ OPTINEURON 1 AMP IN 100 ML NS / IV/ TID
5.INJ PAN 40 MG / IV/OD 
6.INJ HALOPERIDOL 2.5 MG (1/2 AMP ) IN 100 ML NS/ IV/ OD   (X-----X-----I)
7.TAB OXETAL 150 MG BD  ( I -----X -----X
8.RT   1 ) 50 ML WATER HOURLY 
         2) 100 ML MILK 2ND HOURLY 

9.AVOID PROTIEN  RICH DIET
10.BP / PR/ TEMP / SPO2  HOURLY
11.STRICT  I/O CHARTING 
12.GRBS 8 TH HOURLY 
13.ABDOMINAL  GIRTH MONITORING  DAILY

TREATMENT on day 8 (01/03/2021)
S-  
Sensorium improved,Passed stools, 
Complaints of b/l pedal edema. 

O-
Patient i!c/c
Temp- 99.3F
BP -120/70 MMHG
PR - 104BPM
PEDAL EDEMA present-Pitting type
CVS - S1 S2 HEARD 
RR- BAE + NVBS 
P/A - SOFT,  NON TENDER, abdominal girth-88cm
CNS - NO FOCAL NEUROLOGICAL deficits

A - 
DELIRIUM  RESOLVED   SECONDARY  TO ? ALCOHOLIC WITHDRAWAL  ,? HEPATIC ENCEPHALOPATHY 
WITH  ALCOHOLIC HEPATITIS 
WITH  CHOLECYSTITIS,  CHOLELITHIASIS
WITH ? OBSTRUCTIVE  JAUNDICE  
?UTI


P-
1.TAB OFLOXACIN 200 MG XBD  ( 8 AM----- X ------- 8 PM ) 
2.Inj. LASIX BD 80mg--------40mg--------X
3. T.THIAMINE 100mg TID. 
4. T. OPTINEURON TID. 
5. T. PAN 40 MG / PO/OD 
6.INJ HALOPERIDOL 2.5 MG (1/2 AMP ) IN 100 ML NS/ IV/ OD   (X-----X-----I)
7.TAB OXETAL 150 MG BD  ( I -----X -----I)
8.T. UDILIV 300mg PO BD
9.AVOID PROTIEN  RICH DIET
10.BP / PR/ TEMP / SPO2  HOURLY
11.STRICT  I/O CHARTING 
12.GRBS 8 TH HOURLY 
13. Syp.  POTCHLOR 15ml OD
14. T. RIFAGUT 550mg PO BD. 
15.Syp.  HEPAMERZ 15ml PO BD. 
16. Syp. LACTULOSE 15ml PO 6th hrly. 
TREATMENT on day 9 (02/03/2021)
S-  
Sensorium improved,Passed stools, b/l pedal edema increasing. 

O-
Patient i!c/c
Temp- 99.3F
BP -120/70 MMHG
PR - 104BPM
Pitting type pedal edema present. 
CVS - S1 S2 HEARD 
RR- BAE + NVBS 
P/A - SOFT,  NON TENDER 
CNS - NO FOCAL NEUROLOGICAL deficits
Abdominal girth-86cm

A - 
DELIRIUM  RESOLVED   SECONDARY  TO ? ALCOHOLIC WITHDRAWAL  ,? HEPATIC ENCEPHALOPATHY 
WITH  ALCOHOLIC HEPATITIS 
WITH  CHOLECYSTITIS,  CHOLELITHIASIS
WITH ? OBSTRUCTIVE  JAUNDICE  
?UTI


P-
1.TAB OFLOXACIN 200 MG XBD  ( 8 AM----- X ------- 8 PM ) 
2. T. OXAZEPAM X-----X-----2
3. T.THIAMINE 100mg TID. 
4. T. OPTINEURON TID. 
5. T. PAN 40 MG / PO/OD 
6.INJ HALOPERIDOL 2.5 MG (1/2 AMP ) IN 100 ML NS/ IV/ OD   (X-----X-----I)
7.TAB OXETAL 150 MG BD  ( I -----X -----I)
8.T. UDILIV 300mg PO BD
9.AVOID PROTIEN  RICH DIET
10.BP / PR/ TEMP / SPO2  HOURLY
11.STRICT  I/O CHARTING 
12.GRBS 8 TH HOURLY 
13. Syp.  POTCHLOR 15ml OD
14. T. RIFAGUT 550mg PO BD. 
15.Syp.  HEPAMERZ 15ml PO BD. 
16. Syp. LACTULOSE 15ml PO 6th hrly. 
17. FLUID RESTRICTION UPTO 2L/DAY.
18. SALT RESTRICTION <1gm/day.
19. Tepid sponging. 
 2 FFP transfusion done i/v/o derranged coagulation profile.


TREATMENT on day 10 (03/03/2021)
S-  
Sensorium improved,Passed stools, b/l pedal edema increasing. 

O-
Patient is c/c
Temp- 99F
BP -110/70 MMHG
PR - 106BPM
Pitting type pedal edema present. 
CVS - S1 S2 HEARD 
RR- BAE + NVBS 
P/A - Distended Girth-89cms
CNS - NO FOCAL NEUROLOGICAL deficits

A - 
DELIRIUM  RESOLVED   SECONDARY  TO ? ALCOHOLIC WITHDRAWAL  ,? HEPATIC ENCEPHALOPATHY 
WITH  ALCOHOLIC HEPATITIS 
WITH  CHOLECYSTITIS,  CHOLELITHIASIS
WITH ? OBSTRUCTIVE  JAUNDICE  
?UTI


P-
1.TAB OFLOXACIN 200 MG XBD  ( 8 AM----- X ------- 8 PM ) 
2. T. OXAZEPAM X-----X-----2
3. T.THIAMINE 100mg TID. 
4. T. OPTINEURON TID. 
5. T. PAN 40 MG / PO/OD 
6.INJ HALOPERIDOL 2.5 MG (1/2 AMP ) IN 100 ML NS/ IV/ OD   (X-----X-----I)
7.TAB OXETAL 150 MG BD  ( I -----X -----I)
8.T. UDILIV 300mg PO BD
9.AVOID PROTIEN  RICH DIET
10.BP / PR/ TEMP / SPO2  HOURLY
11.STRICT  I/O CHARTING 
12.GRBS 8 TH HOURLY 
13. Syp.  POTCHLOR 15ml OD
14. T. RIFAGUT 550mg PO BD. 
15.Syp.  HEPAMERZ 15ml PO BD. 
16. Syp. LACTULOSE 15ml PO 6th hrly. 
17. FLUID RESTRICTION UPTO 2L/DAY.
18. SALT RESTRICTION <1gm/day.
19. Tepid sponging. 
20. T. SPIRONOLACTONE 100mg X OD. 
21. T. BRONAC 600mg BD. 
Diagnostic and therapeutic ascitic tap done-450ml
TREATMENT on day 11 (04/03/2021)
S-
S-  
Sensorium improved,Passed stools, increasing pedal edema of left leg more than right leg. 

O-
Patient is c/c
Temp- 99.8F
BP -120/70 MMHG
PR - 96BPM
Pitting type pedal edema present. 
CVS - S1 S2 HEARD 
RR- BAE + NVBS 
P/A - Distended girth-90cm
CNS - NO FOCAL NEUROLOGICAL deficits

A - 
DELIRIUM  RESOLVED   SECONDARY  TO ? ALCOHOLIC WITHDRAWAL  ,? HEPATIC ENCEPHALOPATHY 
WITH  ALCOHOLIC HEPATITIS 
WITH  CHOLECYSTITIS,  CHOLELITHIASIS
WITH ? OBSTRUCTIVE  JAUNDICE  
?UTI


P-
1.TAB OFLOXACIN 200 MG XBD  ( 8 AM----- X ------- 8 PM ) 
2. T. OXAZEPAM X-----X-----2
3. T.THIAMINE 100mg TID. 
4. T. OPTINEURON TID. 
5. T. PAN 40 MG / PO/OD 
6.INJ HALOPERIDOL 2.5 MG (1/2 AMP ) IN 100 ML NS/ IV/ OD   (X-----X-----I)
7.TAB OXETAL 150 MG BD  ( I -----X -----I)
8.T. UDILIV 300mg PO BD
9.AVOID PROTIEN  RICH DIET
10.BP / PR/ TEMP / SPO2  HOURLY
11.STRICT  I/O CHARTING 
12.GRBS 8 TH HOURLY 
13. Syp.  POTCHLOR 15ml OD
14. T. RIFAGUT 550mg PO BD. 
15.Syp.  HEPAMERZ 15ml PO BD. 
16. Syp. LACTULOSE 15ml PO 6th hrly. 
17. FLUID RESTRICTION UPTO 2L/DAY.
18. SALT RESTRICTION <1gm/day.
19. Tepid sponging. 
20. T. SPIRONOLACTONE 100mg X OD. 
21. T. BRONAC 600mg BD. 

PT-18sec, INR-1.33

TREATMENT on day 12 (05/03/2021)
S-
Sensorium improved 
Complained of increased pedal edema associated with pain abdomen and distension passed 7 episodes of stools 

O-
PATIENT  IS CONSCIOUS 
COHERNT   
BP 120/70mmhg  
PR 104/min 
RR  25cpm
CVS- s1 s2 HEARD 
RS - B/ L AIR ENTRY PRESENT , NVBS 
P/A - SOFT, NON TENDER, BOWEL SOUNDS + 
CNS - No focal deficits 

A-
ACUTE DECOMPENSATION OF CLD 
DELRIUM (resolved) secondary  TO 
? ALCOHOL WITHDRAWAL
? HEPATIC ENCEPHALOPATHY

P-
1 )  TAB. PAN 40mg /po/BD
2) TAB  OFLOXACIN. 200MG /PO/BD
3)TAB OXETAL 150MG/PO/BD
4) TAB OXAZEPAM. 
5) TAB THAMINE 100MG/ TID
6) TAB OPTINEURON TID
7) TAB UDILIV 300MG /PO/BD
8) TAB RIFAGUT 550MG /PO/BD
9) SYP HEPAMERZ 1.5ML/PO/BD
10) SYP LACTULOSE 15ML /PO/BD
11) AVOID PROTEIN RICH DIET
12) BP/PR/ TEMP/SPO2 HOURLY
13) STRICT I/O CHARTING
14) GRBS 8th HOURLY
15) FLUID RESTRICTION UPTO 2 LITRES/DAY
16) SALT RESTRICTION UPTO 1GM/DAY
17) TEPID SPONGING
18) TAB SPRINOLACTONE 100MG /TID
19) TAB BRONAC 600MG/BD
20) Inj. LASIX IV BD 80-----40-----X

TREATMENT on day 13 (06/03/2021)
S-
Sensorium improved 
Complained of increased pedal edema associated with abdomen distension. 

O-
PATIENT  IS CONSCIOUS 
COHERNT   
Weight- 63--->62kgs
Abdominal girth- 85---86---89---90---91---89cms
BP 110/70mmhg  
PR 74/min 
RR  25cpm
CVS- s1 s2 HEARD 
RS - B/ L AIR ENTRY PRESENT , NVBS 
P/A - SOFT, NON TENDER, BOWEL SOUNDS + 
CNS - No focal deficits 
B/l Pitting pedal edema. 

A-
ACUTE DECOMPENSATION OF CLD 
DELRIUM (resolved) secondary  TO 
? ALCOHOL WITHDRAWAL
? HEPATIC ENCEPHALOPATHY
Alcoholic Hepatitis
UTI( resolved) 

P-
1 )  TAB. PAN 40mg /po/BD
2) TAB  OFLOXACIN. 200MG /PO/BD
3)TAB OXETAL 150MG/PO/BD
4) TAB OXAZEPAM. 
5) TAB THAMINE 100MG/ TID
6) TAB OPTINEURON TID
7) TAB UDILIV 300MG /PO/BD
8) TAB RIFAGUT 550MG /PO/BD
9) SYP HEPAMERZ 1.5ML/PO/BD
10) SYP LACTULOSE 15ML /PO/BD
11) AVOID PROTEIN RICH DIET
12) BP/PR/ TEMP/SPO2 HOURLY
13) STRICT I/O CHARTING
14) GRBS 8th HOURLY
15) FLUID RESTRICTION UPTO 2 LITRES/DAY
16) SALT RESTRICTION UPTO 1GM/DAY
17) TEPID SPONGING
18) TAB SPRINOLACTONE 100MG /TID
19) TAB BRONAC 600MG/BD
20) Inj. LASIX IV BD 80-----40-----X



TREATMENT on day 14(07/03/2021)
S-
Sensorium improved 
Complained of increased pedal edema. 

O-
PATIENT  IS CONSCIOUS 
COHERNT   
Weight- 63--->62kgs
Abd girth-85---86---89---90---91---89---86cms
BP 120/70mmhg  
PR 96/min 
CVS- s1 s2 HEARD 
RS - B/ L AIR ENTRY PRESENT , NVBS 
P/A - SOFT, NON TENDER, BOWEL SOUNDS + 
CNS - No focal deficits 
B/l Pitting pedal edema. 

A-
ACUTE DECOMPENSATION OF CLD 
DELRIUM (resolved) secondary  TO 
? ALCOHOL WITHDRAWAL
? HEPATIC ENCEPHALOPATHY

P-
1 )  TAB. PAN 40mg /po/BD
2) TAB  OFLOXACIN. 200MG /PO/BD
3)TAB OXETAL 150MG/PO/BD
4) TAB OXAZEPAM. 
5) TAB THAMINE 100MG/ TID
6) TAB OPTINEURON TID
7) TAB UDILIV 300MG /PO/BD
8) TAB RIFAGUT 550MG /PO/BD
9) SYP HEPAMERZ 1.5ML/PO/BD
10) SYP LACTULOSE 15ML /PO/BD
11) AVOID PROTEIN RICH DIET
12) BP/PR/ TEMP/SPO2 HOURLY
13) STRICT I/O CHARTING
14) GRBS 8th HOURLY
15) FLUID RESTRICTION UPTO 2 LITRES/DAY
16) SALT RESTRICTION UPTO 1GM/DAY
17) TEPID SPONGING
18) TAB SPRINOLACTONE 100MG /TID
19) TAB BRONAC 600MG/BD
20) Inj. LASIX IV BD 80-----40-----X

TREATMENT on day 15(08/03/2021)
S-
Sensorium improved 
Complained of increased pedal edema. 

O-
PATIENT  IS CONSCIOUS 
COHERNT   
Weight- 63--->62--->60kgs
Abd girth-85---86---89---90---91---89---86---84cms
BP 120/70mmhg  
PR 96/min 
CVS- s1 s2 HEARD 
RS - B/ L AIR ENTRY PRESENT , NVBS 
P/A - SOFT, NON TENDER, BOWEL SOUNDS + 
CNS - No focal deficits 
B/l Pitting pedal edema. 

A-
ACUTE DECOMPENSATION OF CLD 
DELRIUM (resolved) secondary  TO 
? ALCOHOL WITHDRAWAL
? HEPATIC ENCEPHALOPATHY
Alcoholic Hepatitis
UTI( resolved) 

P-
1 )  TAB. PAN 40mg /po/BD
2) TAB  OFLOXACIN. 200MG /PO/BD
3)TAB OXETAL 150MG/PO/BD
4) TAB OPTINEURON TID
5) TAB UDILIV 300MG /PO/BD
6) SYP HEPAMERZ 1.5ML/PO/BD
7) SYP LACTULOSE 15ML /PO/BD
8) AVOID PROTEIN RICH DIET
9) BP/PR/ TEMP/SPO2 HOURLY
10) STRICT I/O CHARTING
11) GRBS 8th HOURLY
12) FLUID RESTRICTION UPTO 2 LITRES/DAY
13) SALT RESTRICTION UPTO 1GM/DAY
14) TEPID SPONGING
15) TAB SPRINOLACTONE 100MG /TID
16) TAB BRONAC 600MG/BD
17) Inj. LASIX IV BD 80-----80----X



TREATMENT on day 16(09/03/2021)
S-
Sensorium improved 
Left leg swelling and pain
No Sleeplessness


O-
PATIENT  IS CONSCIOUS 
COHERNT   
Weight- 63--->62--->60kgs
Girth-85-86-89-90-91-89-86-84-83-82cms
BP 110/70mmhg  
PR 96/min 
CVS- s1 s2 HEARD 
RS - B/ L AIR ENTRY PRESENT , NVBS 
P/A - SOFT, NON TENDER, BOWEL SOUNDS + 
CNS - No focal deficits 
B/l Pitting pedal edema. 

A-
ACUTE DECOMPENSATION OF CLD 
DELRIUM (resolved) secondary  TO 
? ALCOHOL WITHDRAWAL
? HEPATIC ENCEPHALOPATHY
Alcoholic Hepatitis
UTI( resolved) 

P-
1 )  TAB. PAN 40mg /po/BD
2) TAB  OFLOXACIN. 200MG /PO/BD
3)TAB OXETAL 150MG/PO/BD
4) TAB OPTINEURON TID
7) SYP LACTULOSE 15ML /PO/BD
8) AVOID PROTEIN RICH DIET
9) BP/PR/ TEMP/SPO2 HOURLY
10) STRICT I/O CHARTING
11) GRBS 8th HOURLY
12) FLUID RESTRICTION UPTO 2 LITRES/DAY
13) SALT RESTRICTION UPTO 1GM/DAY
14) TEPID SPONGING
15) TAB SPIRONOLACTONE
        200-----200-----50
16) TAB BRONAC 600MG/BD
17) Inj. LASIX IV BD 80mg-------x-------80mg
Venous doppler of left leg: 

TREATMENT on day 17(10/03/2021)
S-
Sensorium improved 
Right leg swelling and pain. 
Patient is speeping well. 

O-
PATIENT  IS CONSCIOUS 
COHERNT   
Weight- 63--->62--->60--->59gs
Girth-85-86-89-90-91-89-86-84-83-82cms
BP 110/70mmhg  
PR 96/min 
CVS- s1 s2 HEARD 
RS - B/ L AIR ENTRY PRESENT , NVBS 
P/A - SOFT, NON TENDER, BOWEL SOUNDS + 
CNS - No focal deficits 
B/l Pitting pedal edema. 

A-
ACUTE DECOMPENSATION OF CLD 
DELRIUM (resolved) secondary  TO 
? ALCOHOL WITHDRAWAL
? HEPATIC ENCEPHALOPATHY
Alcoholic Hepatitis
UTI( resolved) 

P-
1 )  TAB. PAN 40mg /po/BD
2) TAB  OFLOXACIN. 200MG /PO/BD
3)TAB OXETAL 150MG/PO/BD
4) SYP LACTULOSE 15ML /PO/BD
5) AVOID PROTEIN RICH DIET
6) BP/PR/ TEMP/SPO2 HOURLY
7) STRICT I/O CHARTING
8) GRBS 8th HOURLY
9) FLUID RESTRICTION UPTO 2 LITRES/DAY
10) SALT RESTRICTION UPTO 1GM/DAY
11) TEPID SPONGING
12) TAB SPIRONOLACTONE
        200-----200-----50
13) TAB BRONAC 600MG/BD
14) Inj. LASIX IV BD 80mg-------x-------80mg
15) Tab. PREDNISOLONE 40mg OD. 
16) Tab. UPRISE D3 in milk/weekly once. 

TREATMENT on day 18(11/03/2021)
S-
Sensorium improved 
Left leg swelling and pain reduced. 
Right leg swelling decreased. 
Patient is speeping well. 

O-
PATIENT  IS CONSCIOUS 
COHERNT   
Weight- 63--->62--->60--->59--->57gs
Girth-85-86-89-90-91-89-86-84-83-82-81cms
BP 110/70mmhg  
PR 96/min 
CVS- s1 s2 HEARD 
RS - B/ L AIR ENTRY PRESENT , NVBS 
P/A - SOFT, NON TENDER, BOWEL SOUNDS + 
CNS - No focal deficits 
B/l Pitting pedal edema. 

A-
ACUTE DECOMPENSATION OF CLD 
DELRIUM (resolved) secondary  TO 
? ALCOHOL WITHDRAWAL
? HEPATIC ENCEPHALOPATHY
Alcoholic Hepatitis
UTI( resolved) 

P-
1 )  TAB. PAN 40mg /po/BD
2) TAB  OFLOXACIN. 200MG /PO/BD
3)TAB OXETAL 150MG/PO/OD/HS
4) SYP LACTULOSE 15ML /PO/BD
5) BP/PR/ TEMP/SPO2 HOURLY
6) STRICT I/O CHARTING
7) GRBS 8th HOURLY
8) FLUID RESTRICTION UPTO 2 LITRES/DAY
9) TEPID SPONGING
10) TAB SPIRONOLACTONE
        200-----200-----50
11) TAB BRONAC 600MG/BD
12) Inj. LASIX IV BD 80mg-------x-------80mg
13) Tab. PREDNISOLONE 40mg OD. 
14) Tab. UPRISE D3 in milk/weekly once. 
15) Tab. ZINCOVIT PO TID


TREATMENT on day 19(12/03/2021)
S-
Sensorium improved 
Left leg swelling and pain reduced. 
Patient is speeping well. 

O-
PATIENT  IS CONSCIOUS 
COHERNT   
Weight- 63--->62--->60--->59--->57--->54kgs
Girth-85-86-89-90-91-89-86-84-83-82-80cms
BP 110/70mmhg  
PR 90bpmin 
CVS- s1 s2 HEARD 
RS - B/ L AIR ENTRY PRESENT , NVBS 
P/A - SOFT, NON TENDER, BOWEL SOUNDS + 
CNS - No focal deficits 
B/l Pitting pedal edema-decreased.

A-
ACUTE DECOMPENSATION OF CLD 
DELRIUM (resolved) secondary  TO 
? ALCOHOL WITHDRAWAL
? HEPATIC ENCEPHALOPATHY
Alcoholic Hepatitis
UTI( resolved) 

P-
1 )  TAB. PAN 40mg /po/BD
2)TAB OXETAL 150MG/PO/HS
3) SYP LACTULOSE 15ML /PO/8th hrly. 
4) AVOID PROTEIN RICH DIET
5) BP/PR/ TEMP/SPO2 HOURLY
6) STRICT I/O CHARTING
7) GRBS 8th HOURLY
8) FLUID RESTRICTION UPTO 2 LITRES/DAY
9) SALT RESTRICTION UPTO 1GM/DAY
10) TAB SPIRONOLACTONE PO BD
        200----X-----200
11) TAB BRONAC 600MG/BD
12) Inj. LASIX IV BD 80mg-------x-------40mg
13) Tab. PREDNISOLONE 40mg OD. 
14) Tab. UPRISE D3 in milk/weekly once. 
15)T. ZINCOVIT PO TID
TREATMENT on day 20(13/03/2021)
S-
Sensorium improved 
Left leg swelling and pain reduced. 
Patient is speeping well. 

O-
PATIENT  IS CONSCIOUS 
COHERNT   
Weight- 63--->62--->60--->59--->57--->54kgs
Girth-85-86-89-90-91-89-86-84-83-82-80-77cms
BP 140/70mmhg  
PR 86bpmin 
CVS- s1 s2 HEARD 
RS - B/ L AIR ENTRY PRESENT , NVBS 
P/A - SOFT, NON TENDER, BOWEL SOUNDS + 
CNS - No focal deficits 
B/l Pitting pedal edema-decreased.

A-
ACUTE DECOMPENSATION OF CLD 
DELRIUM (resolved) secondary  TO 
? ALCOHOL WITHDRAWAL
? HEPATIC ENCEPHALOPATHY
Alcoholic Hepatitis
UTI( resolved) 

P-
1 )  TAB. PAN 40mg /po/BD
2) TAB SPIRONOLACTONE PO BD
        200-----100-----x
3) SYP LACTULOSE 15ML /PO/12th hrly. 
4) TAB BRONAC 600MG/BD
5) BP/PR/ TEMP/SPO2 HOURLY
6) STRICT I/O CHARTING
7) GRBS 8th HOURLY
8) FLUID RESTRICTION UPTO 2 LITRES/DAY
9) SALT RESTRICTION UPTO 1GM/DAY
10) Inj. LASIX IV OD 80----X----X
11) Tab. PREDNISOLONE 40mg OD. 
12) Tab. UPRISE D3 in milk/weekly 
13) T. ZINCOVIT PO TID
TREATMENT on day 21(14/03/2021)
S-
Sensorium improved 
Left leg swelling and pain reduced. 
Patient is speeping well. 
No fresh complaints. 

O-
PATIENT  IS CONSCIOUS 
COHERNT   
Weight- 63--->62--->60--->59--->57--->54kgs
Girth-85-86-89-90-91-89-86-84-83-82-80-77cms
BP 110/70mmhg  
PR 76bpmin 
CVS- s1 s2 HEARD 
RS - B/ L AIR ENTRY PRESENT , NVBS 
P/A - SOFT, NON TENDER, BOWEL SOUNDS + 
CNS - No focal deficits 
B/l Pitting pedal edema-decreased.

A-
ACUTE DECOMPENSATION OF CLD 
DELRIUM (resolved) secondary  TO 
? ALCOHOL WITHDRAWAL
? HEPATIC ENCEPHALOPATHY
Alcoholic Hepatitis
UTI( resolved) 

P-
1 )  TAB. PAN 40mg /po/BD
2) TAB SPIRONOLACTONE PO BD
        200-----100-----x
3) SYP LACTULOSE 15ML /PO/12th hrly. 
4) TAB BRONAC 600MG/BD
5) BP/PR/ TEMP/SPO2 HOURLY
6) STRICT I/O CHARTING
7) GRBS 8th HOURLY
8) FLUID RESTRICTION UPTO 2 LITRES/DAY
9) SALT RESTRICTION UPTO 1GM/DAY
10) Inj. LASIX IV OD 80----X----X
11) Tab. PREDNISOLONE 40mg OD. 
12) Tab. UPRISE D3 in milk/weekly 
13) T. ZINCOVIT PO TID
TREATMENT on day 22(15/03/2021)
S-
Sensorium improved 
Left leg swelling and pain reduced. 
Patient is speeping well.
No  fresh complaints. 

O-
PATIENT  IS CONSCIOUS 
COHERNT   
Weight- 63--->62--->60--->59--->57--->54kgs
Girth-85-86-89-90-91-89-86-84-83-82-80-77cms
BP 140/70mmhg  
PR 86bpmin 
CVS- s1 s2 HEARD 
RS - B/ L AIR ENTRY PRESENT , NVBS 
P/A - SOFT, NON TENDER, BOWEL SOUNDS + 
CNS - No focal deficits 
B/l Pitting pedal edema-decreased.

A-
ACUTE DECOMPENSATION OF CLD 
DELRIUM (resolved) secondary  TO 
? ALCOHOL WITHDRAWAL
? HEPATIC ENCEPHALOPATHY
Alcoholic Hepatitis
UTI( resolved) 

P-
1 )  TAB. PAN 40mg /po/BD
2) TAB SPIRONOLACTONE PO BD
        200-----100-----x
3) SYP LACTULOSE 15ML /PO/12th hrly. 
4) TAB BRONAC 600MG/BD
5) BP/PR/ TEMP/SPO2 HOURLY
6) STRICT I/O CHARTING
7) GRBS 8th HOURLY
8) FLUID RESTRICTION UPTO 2 LITRES/DAY
9) SALT RESTRICTION UPTO 1GM/DAY
10) Tab. PREDNISOLONE 40mg OD. 
11) Tab. UPRISE D3 in milk/weekly 
12) T. ZINCOVIT PO TID

TREATMENT on day 23(16/03/2021)
S-
Sensorium improved 
Left leg swelling and pain reduced. 
Patient is speeping well.
No  fresh complaints. 

O-
PATIENT  IS CONSCIOUS 
COHERNT   
Weight- 63--->62--->60--->59--->57--->54kgs
Girth-85-86-89-90-91-89-86-84-83-82-80-77cms
BP 120/70mmhg  
PR 90bpmin 
CVS- s1 s2 HEARD 
RS - B/ L AIR ENTRY PRESENT , NVBS 
P/A - SOFT, NON TENDER, BOWEL SOUNDS + 
CNS - No focal deficits 
B/l Pitting pedal edema-decreased.

A-
ACUTE DECOMPENSATION OF CLD 
DELRIUM (resolved) secondary  TO 
? ALCOHOL WITHDRAWAL
? HEPATIC ENCEPHALOPATHY
Alcoholic Hepatitis
UTI( resolved) 

P-
1 )  TAB. PAN 40mg /po/BD
2) TAB SPIRONOLACTONE PO BD
        200-----100-----x
3) SYP LACTULOSE 15ML /PO/12th hrly. 
4) TAB BRONAC 600MG/BD
5) BP/PR/ TEMP/SPO2 HOURLY
6) STRICT I/O CHARTING
7) GRBS 8th HOURLY
8) FLUID RESTRICTION UPTO 2 LITRES/DAY
9) SALT RESTRICTION UPTO 1GM/DAY
10) Tab. PREDNISOLONE 40mg OD. 
11) Tab. UPRISE D3 in milk/weekly 
12) T. ZINCOVIT PO TID

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