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Abstract: A 71-year-old female patient complained that half a month ago, for unknown reasons, she felt generalized weakness and pain in the right upper abdomen, accompanied by bilateral lower limb edema, during which no treatment was taken, and came to our hospital for further treatment.
Basic information】Female, 71 years old
Disease Type】Cirrhosis of the liver
Hospital】The First Hospital of China Medical University
Time of consultation】April 2016
Treatment plan】Medication (ursodeoxycholic acid capsules, adenosylmethionine butanedisulfonate enteric tablets, human albumin, hydrochlorothiazide tablets)
[Treatment period] In-hospital treatment for 5 days, with a follow-up visit at any time when the body is not feeling well
Treatment effect】The disease was well controlled, and the pain in the right upper abdomen, general weakness, and edema of both lower limbs basically disappeared.
I. Initial consultation
The first time I saw the patient in the hospital, he told me that half a month ago, he suddenly felt general weakness and pain in the right upper abdomen, accompanied by edema in both lower limbs, without nausea, vomiting, fever, acid reflux and heartburn, and did not take corresponding treatment measures. I first examined the patient and found that the skin around the patient’s face and orbits was dull and lusterless, showing the face of liver disease, with mild finger sunken edema in both lower limbs. The portal vein was about 11 mm wide, and the bile ducts inside and outside the liver were not dilated. Combined with the examination results and the patient’s physical signs, the diagnosis of cirrhosis was made.
II. Treatment history
The patient’s liver function was damaged due to the disease, and the hepatocytes were damaged and the liver’s ability to synthesize albumin was reduced. Therefore, I suggested the patient to take pharmacological treatment by applying human albumin to gradually restore the patient’s ability to synthesize albumin, in order to prevent the development of hypoproteinemia during the disease, which could induce ascites. The patient was given hydrochlorothiazide tablets to reduce the patient’s edema by diuresis, and also to take hepatocyte-protective drugs, ursodeoxycholic acid capsules and adenosylmethionine butanedisulfonate enteric tablets, so as to avoid further damage to liver function. After hearing this, the patient said he would actively cooperate with the treatment and would take the medication on time.
III. Treatment effect
On the second day of drug treatment, the patient felt stronger than before treatment, and the pain in the right upper abdomen and edema in both lower limbs were relieved. On the third day of drug treatment, the patient’s condition improved significantly, with normal diet, sleep and urination and defecation, clear consciousness and good mental status, and he reported that he had no obvious right upper abdominal pain, general weakness and edema of both lower limbs. On the fifth day of drug treatment, the disease was better controlled and the pain in the right upper abdomen, general weakness and edema of both lower limbs basically disappeared, so the patient was discharged immediately.
IV. Notes
I was very pleased to see that the patient’s symptoms were reduced, and told the patient that although cirrhosis cannot be cured, the disease can usually be better controlled by taking medication regularly, so the patient should take medication regularly during the disease, and should not stop taking medication or reduce the dosage of medication privately, otherwise the disease will easily deteriorate or progress. In addition, I also suggested the patient to consume more high quality and high protein diet, such as eggs, pork, fish, milk, soybean skin, etc., to meet the body’s demand for nutrition and energy, and to assist in repairing the damaged liver cells, thus promoting the improvement of the disease.
V. Personal insight
The disease of liver cirrhosis is relatively harmful to the human body, and if treatment is not taken in time, the disease may even develop into hepatic encephalopathy at an advanced stage, thus endangering one’s life. The 71-year-old female patient in this case did not blindly take medication on her own after finding abnormal health discomfort and sought medical help after a period of time without relief, thus enabling the disease to be better controlled. It is recommended to seek medical attention immediately when abnormal health symptoms are detected, and family members should also pay more attention to the elderly in the family and give them care and love.