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DISCHARGE SUMMARY

DEPARTMENT OF HEPATOLOGY
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION AND RESEARCH

Name Rajbir Age 40 Years Sex Male


Father’s name Zile Ji C.R.No. 20180568653 Admission 2018075842
2 No
Address 2180, Jind, Ujhana, Haryan Phone no. 9416664804
DOA 06-Oct-2018 DOD -Oct-2018 Consultant Dr. RK
in-charge Dhiman

DIAGNOSIS

CHANDIGARH – 160012 (INDIA)

Chief Complaints:
Abdominal distension x 4 month
Jaundice x 3 month

BGH and HOPI: -


Patient was apparently well till 2013 when he was diagnosed to be HCV +ve and
was started on interferon therapy. He was asymptomatic till June 2018 when he
started to have jaundice and abdominal distwnsion. He was evaluated outside and
informed to have liver cirrhosis and was started on diyuretics. Since last 2 months
patient is requiring LVP every 15-20 days. No h/o altered sensorium, hematemesis,
malena, fever.
No h/o loss of weight/ appetite.
No h/o cough, fever, burning micturition.

Past History: No h/o T2DM, HTN, TB, BA.

Family history: Not significant.

O/E: Per abdomen-


Conscious, oriented, co-operative Soft, non-tender, distended, Liver not
PR-82/min palpable. Spleen not palpable. Free fluid
BP- 112/70mm Hg +, umblical hernia +, BS+
Temp- 98.6 F
RR- 18/min CVS: S1, S2. No murmur.
SpO2 – 97% RA RS- B/L NVBS.
P-, I+, CY - ,CL-,LAP -,PE- CNS-.
HMF intact
No focal neurological deficits.
No flaps.

Investigations:-
DATE 08-10-18 15-10-18 22-10-18
Hb 10.8 10.5 102
Plat×103 97 76 93
TLC 5800 4400 3900
DLC 58/29/08/05
Na/K/Cl 135/4.2/105 136/4.2/102 136/3.7/106
Urea/Creatinine 20/1.14 20/0.84 18/0.77
Ca/P/Mg 7.7/3.1 7.9/3.6 8.9/3.4
T. Bil /C.Bil 2.6/0.75 2.2/0.72 3.7/1.1
AST/ALT/ALP 67/19/103 41/12/90 43/14/106
TP/Alb 6.2/2.18 6.2/3.06 7.4/4.0
PT/PTI/INR/APTT 18.7/71/1.3/48.6 22.5/59/1.54/50.6 19.8/67/1.3/50.6
Other Investigations :-
Urine RME- NAD
HBsAg (26-9-18)-NR
Anti HCV (26-9-18) – reactive
AIH (08-10-18) - Neg
HEV IgM (9-10-18)- Positive ; HAV- Neg
HbA1C (10-10-18)-5.2
TFT (08-10-18) TSH-3.51, T3-0.804, T4-6.25
(08-10-18)-24 Hr urinary- Prt-19, Cr-977, Na-6, K-14, Cl-18
Homocysteine (9-10-18) - 5.49
(09-10-18) AFP-1.5, CA-19-9-194.7, CEA-3.62
Ascitic fluid (07/10/18)- TC- No WBC; P-0.6, S-224
USG Abdomen (07-10-18) – liver-14 cm, heterogeneous. Spleen-12cm. f/s/o
chronic liver disease with portal hypertension.
Endoscopy (18-10-18) - Eso-Gd-1-2, 4 col. Vx. No RCS. Multiple post EVL scar,
2 linear ulcer seen at GE junction one of them 40 cm.
Stomach- Fundus- No GOV, severe PHG; Body-severe
PHG; antrum- erosion seen.
Duodenum- D1- jejunalisation seen, D2- seen.

COURSE AND MANAGEMENT:

ADVICE AT DISCHARGE:

As per discharge booklet

Dr. Nadim Rahman Dr. Akash Roy


Ward JR Ward SR