Patient Particulars - Age -43 kg; Height - 5' 4''; Weight - 40kg; BP - 100/60; Sugar- 123.
Chief Complaints - Loss of Appetite, Abdomen swollen, Pain during urination, Diarrhoea
History of Illness - Currently admitted in local hospital. Has abdominal swelling. Pain during urination and frequency increases on medication. Urine is yellow in colour. Passes stool about 10/12 times a day. Had Tuberculosis at 29 years. Jaundice at 32 years. Was operated for Hernia about four or five months back. Chronic Alcoholic since the last 8 years. Consumes alcohol almost daily.
Health Professional Update from PCMS, Bhopal on the date of admission 10th April 2013. Patient arrived here in Bhopal from Mathabhanga after a 2000 kms train journey from West Bengal.
SOAP format:
Subjective: As noted from attached patient's letter above and also on further history taking patient has developed intermittent fever and abdominal pain along with intermittent altered sensorium and alteration of diurnal sleep rhythm. Has been drinking even in the last week.
Objective: Massive ascites with umbilical hernia and hydrocoele. ( Subjectively patient insisted that he be operated for the umbilical hernia on top priority and was counseled to the contrary.
Assessment:
Possible Hepatic Encephalopathy precipitated due to Spontaneous Bacterial Peritonitis SBP
Plan: Ascitic tap (both diagnostic and therapeutic). Begin IV antibiotics for SBP and Lactulose to keep 2-3 loose stools per day. Alcohol de-addiction counseling.
ArogyaUDHC