DISCHARGE SUMMARY

DEPARTMENT OF HEPATOLOGY
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION AND RESEARCH
CHANDIGARH – 160 012 (INDIA)

Name SURAJPAL Age 48 YEARS Sex MALE

Father’s name GIRWAR SINGH C.R. 201802810348 Admission 2018093195
No. No
Address 5234 rupanagar tapariyan punjab Phone no. 9915649320
DOA 08-12-2018 DOD 18-12-2018 Consultant Dr. Ajay Kumar
Incharge Duseja

DIAGNOSIS ACLF APASL

Acute – Hep B Reactivation
Chronic – Hep B Related Cirrhosis of Liver
Grade III Ascites
Spontaneous Bacterial Peritonitis
Post EVL on 11/12/18
Left Gluteal Abscess
MELD
AARC

CHIEFCOMPLAINTS:
Abdominal distension x 1 month
Left gluteal abscess x 1 month.
BGH and HOPI:
Patient was apparently asymptomatic 1year back when he got his USG Abdomen
done for generalized weakness in April 2018 shrunken liver, coarse hepatic echo
texture & surface irregularity s/o cirrhotic morphology and splenomegaly. Then he
came to PGIMER under hepatology OPD. Detected to be HBsAg positive, started
on tenofovir. Now left treatment Rx for last 2 month. Now p/w c/o abdominal
distension for 1 month. c/o left gluteal abscess for1 month with h/o some
intramuscular injection.
No h/o fever,GI bleeding, decreased urine output
No h/o altered sensorium/ insomnia / blood transfusion, no h/o hospitalization
Past h/o: Per abdomen-
No h/o TB/BA/T2DM/BA/HTN Distension, Non-tender, liver/ spleen
O/E: not palpable. Horse shoe dullness +,
Conscious, oriented, co-operative BS (+)
PR-90 /min FF(+)
BP- 110/70 mm Hg CVS.: S1, S2 , no murmur.
Temp- 98.6 F
RS- B/L NVBS
RR- 18/min
SpO2 – 97% RA CNS-.
P-, I+, CY -, CL-, LAP -, PE- HMF intact
E4V5M6

DATE 08-12-18 13-12 15-12

Hb gm% 11.1 11.2
Plat×103 per cu.mm 76 64
TLC /cu.mm 15200 3600
Na/K/Cl 127/4.26/102 128/3.66/101 132/3.42/98
Urea/Creatinine 39/1.23 24/0.93 19/1.03
Ca/P/Mg 7.7/3.6/1.98 7.6/1.8/2.18 7.7/2.0/1.97
T. Bil /C.Bil 8.21/3.79 9.18/4.71 6.89/3.81
AST/ALT/ALP 571/292/228 255/128/119 233/104/141
TP/Alb 6.1/1.87 5.3/2.32 5.9/2.61
PT/PTI/INR/APTT 26.2/51/1.77/44 66/36/36.8/2.40 73.9/37.1/36/2.42
A/F W/U-08/12- TC/DC- 8000/ P90/L10
P/S-0.35/101
ADA- 9.0
SAAG- 1.87/0.22
09/12-TC/DC- 1000/ predominantly lymphocyte.
11/12-TC/DC- 860/N80/L20
-P/S-0.7/135
-15/12- TC/DC- 20/ predominantly polymorphs
Anti HCV- NR
Anti HEV- NR
Anti HBc total- Positive.
Anti HAV Ig M- NR
HbsAG- Positive
HbeAg- positive
PUS C/S- sterile.
Urine REME- NAD
Urine spot Na/K- 117/11
Procalcitonin- 0.447
USG w/a- CLD with Portal hypertension with gross ascites

COURSE AND MANAGEMENT-

48/M Non alcoholic, Biddi smoker k/c/o hep B related cirrhosis with portal hypertension
was on Tenofovir since April 2018. Patient discontinued treatment for last 2 months and
now presented with abdominal distension and Left gluteal abscess for 1 month. A
diagnosis of ACLF (APASL) was kept Acute being hep B Flare and chronic being hep B
related cirrhosis. On examination patient had jaundice and grade III ascites. Ascitic fluid
analysis revealed high SAAG low protein ascites with SBP. Patient was started on Inj
Piperacillin Tazobactam which was later hiked to inj Imipenem and Teicoplanin in view
of partial response. Patient was also started on salt restricted diet, high protein diet and
inj Albumin OD & tab Dytor plus 5/50 OD. General surgery consultation was taken for
Lt gluteal abscess and advised alternate day dressing for the same. UGI endoscopy
was done and EVL was done in view of Grade II varices. Patient was restarted on
Tenofovir & HBeAg & HBVDNA was sent. Patient improved with resolution of SBP & is
now being discharged in hemodynamically stable condition to follow up in Hepatology
OPD.
ADVICE AT DISCHARGE: as per discharge booklet

F/u I after 2 weeks in hepatology OPD on Monday with CBC, RFT, LFT

DR. Prashant/Sulabh DR. Akash Prof. Ajay Kumar Duseja

Ward JR Ward SR Consultant