34 year old male

GM Blog: 34 year old male patient 

NOTE
This is an ongoing case and will be updated 
The reference link (if any) will be mentioned at the bottom.

Date of admission: 25/02/22

CHIEF COMPLAINT:- YELLOWISH DISCOLORATION  of eyes and urine since7-8 days
c/o abdominal distension since 7days

HISTORY OF PRESENT ILLNESS- 

pt was apparently asymptomatic 7 months back, then the first time he had yellowish discoloration of eyes he was admitted to a local hospital and was diagnosed with alcoholic liver disease and was advised to stop alcohol.

2 months back his brother expired, out of agony he again started drinking excess alcohol 180-360 ml since 40 days.

patient developed progressive distension of abdomen associated with yellowish discoloration of eyes and urine.

h/o fever on and off since 1 week

h/o constipation since 2 days

no h/o melena, hematemesis ,no sleep disturbances

h/o of weakness since 10 days

PAST HISTORY:

No history of hypertension, diabetes
no history of CAD ,asthma
no history of surgeries, radiation ,blood transfusion

PERSONAL HISTORY:
Married 
Factory worker
Diet: mixed. ( Non vegetarian)
Appetite: normal
Sleep: Adequate
Micturition: Regular
bowel -constipation since 2 days
Addictions-alcohol-whisky 180-360 ml daily

FAMILY HISTORY:
Not significant 

GENERAL EXAMINATION:
Patient is conscious, coherent, co-operative.
He is well oriented to time, place and person. 
He is moderately built 
Moderately nourished  
Pallor - absent
icterus present
No cyanosis
No clubbing
No Edema 
No Lymphadenopathy 

VITALS :  
Pulse Rate : 80 bpm
Blood pressure : 80/50mmhg 
Respiratory Rate : 16 /min
SPO2 : 98 % at RA 


SYSTEMIC EXAMINATION : 

CARDIOVASCULAR SYSTEM :  

S1 and S2 heard, no murmurs heard 

RESPIRATORY SYSTEM : 
Shape of chest: normal
Position of trachea: central
dyspnoea absent
Breath sound : vesicular 


CNS : 
Level of consciousness: alert
Speech: normal
No abnormality detected

ABDOMINAL EXAMINATION:
Distended
non tender 
Soft
Free fluid present
No palpable mass
Liver and spleen : non palpable
Bowel sounds present




Investigations-


USG


ECG


Diagnosis-Cirrhosis secondary to alcohol with portal hypertension with gross ascites
with hepatic encephalopathy

Treatment-
1.inj thiamine 1 amp in 100 ml ns iv/bd
2.inj pan 40 mg iv/od
3.in zofer 4 mg iv/od
4.tab lasix 20 mg po/bd
5.tab aldactone 50 mg po /od
6.bp/pr/temp monitoring 4th hourly

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