A case of 35 year old male

This is an online E log book to discuss our patient's de-identified health data shared after taking his signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

A 35 year old male patient came to casuality with the chief complaints of 

Unresponsiveness since 4am morning

Yellowish discoloration of eyes since 6 months

Abdominal distension since 1 week

Pedal edema since 1 week

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic  6 yrs (2014) back then he developed yellowish discoloration of eyes , bilateral pedal odema which in pitting in nature and abdominal distension went to local hospital and diagnosed with Chronic liver disease.

Patient consumed alcohol since 20 years

Since then patient was on irregular medication and continued taking alcohol intermittently.

History of increased bilateral pedal odema which is pitting in nature since 1 week 

History of increased abdominal distension since 1 week

Since 4 days, patient has c/o fever subsided now used 4 tablets of DOLO

C/o loose stools 4-5 episodes per day,no h/o malena , pain abdomen

C/o nausea and loss of appetite

C/o altered sensorium  not responding to commands

No h/o weakness and no h/o involuntary movements

PAST HISTORY:

Not a known case of HTN , DM , Asthma , Epilepsy

PERSONAL HISTORY:
 
Diet - Mixed
Appetite - normal
Sleep - adequate
Bowel & bladder movements - Regular
Addictions - Regular intake of alcohol (180ml) since 20 years


FAMILY HISTORY:

No similar complaints in the family

GENERAL EXAMINATION:

Patient is conscious , coherent and cooperative &
Thin built and malnourished.

Bilateral pitting type of pedal odema present
Icterus present
No pallor , cyanosis , clubbing and lymphadenopathy

Vitals:

Temp : Afebrile
BP : 100/80 mm Hg
PR : 105 bpm
RR : 25 cpm
GRBS : 33 mg / dl
SpO2 : 91 % @ RA

SYSTEMIC EXAMINATION:

CVS : S1S2 + , No murmurs
RS : BAE + , NVBS +
P/A : Soft , Nontender , BS +
CNS : Response to pain

CLINICAL IMAGES:

Icterus - present
B/L Pitting type of pedal odema - present
Abdominal distension
INVESTIGATIONS:
PROVISIONAL DIAGNOSIS:

HEPATIC ENCEPHALOPATHY SECONDARY TO LIVER FAILURE
RECURRENT HYPOGLYCEMIA
K/C/O CHRONIC LIVER DISEASE WITH GROSS ASCITES AND SPLENOMEGALY(PORTAL HTN)


TREATMENT:

INJ.LASIX 20 MG/IV/BD
TAB.ALDACTONE 50 MG/RT/BD
INJ.25% DEXTROSE 100ML/IV/SOS IF GRBS<60 MG/DL
SYP. LACTULOSE 20 ML/PO/BD
INJ. THIAMINE 1 AMP IN 100 ML NS/IV/TID
GRBS CHECK HOURLY
BP/PR/TEMP CHARTING HOURLY
T. UDILIV 300 MG/ RT/BD
SYP. HEPAMERZ 2 TBSP/RT/BD
T RIFAXIMIN 550 MG /RT/BD
ENEMA 12 TH HOURLY
STRICT I/O CHARTING
INJ.CEFOTAXIME 2G /IV/BD

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