32/M CHRONIC LIVER DISEASE
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT
A 32 years male patient driver by occupation came to casuality with chief complaints of abdominal distention, pedal edema since 10 days and yellowish discoloration of eyes since 20 days
HISTORY OF PRESENT ILLNESS :-
Patient was apparently asymptomatic 20 years ago and at the age of 10, patient developed one episode of seizure for which he did not use any medication and seizures subsided by itself.
About 10 years ago the patient had developed scaly lesions over the legs and hands for which he had diagnosed as Psoriasis and since then he was on medication.
About one year ago patient developed yellowish discoloration of eyes for which he used herbal medication for about six days. Again after three months patient developed similar complaints(Yellowish discoloration of eyes) for which he used herbal medication for about seven days.
Now, since 20 days patient is having yellowish discoloration of sclera and distention of abdomen and pedal edema since 10 days.
PAST HISTORY:
Patient is a known case on pulmonary hypertension and he is on medication.
Patient is not a known case of diabetes, tuberculosis,asthma, epilepsy.
PERSONAL HISTORY:
Diet - mixed
Appetite-Decreased
Bowel and Bladder movements-Regular with burning micturition
Sleep- adequate
Addictions
""Alcohol intake around 180 ml since 7yrs "" daily
Occasional smoker
ON EXAMINATION:
Patient was conscious, coherent, cooperative and we'll oriented to time place and person
GENERAL PHYSICAL EXAMINATION:
Pallor-Present
Icterus- Present
Cyanosis- Absent
Clubbing- Absent
Generalized lymphadenopathy- Absent
Vitals
Temperature- Afebrile
Pulse rate -90bpm
Respiratory rate - 16cpm
Blood pressure-120/70mmHg
sPo2 98% at room temperature
SYSTEMIC EXAMINATION :
CVS: Inspection
Chest wall is bilaterally symmetrical.
No precordial bulge is seen
Palpation
JVP- Normal
Apex beat -felt in the left 5th intercoastal space in the mid clavicular line
Auscultation
S1&S2 are heard,no murmur found.
RESPIRATORY SYSTEM
Position of trachea- central
Bilateral air entry, normal vesicular breath sounds are heard.
No added sounds
CNS Examination
Patient is conscious coherent and well oriented towards time.
Speech is normal
No signs of meningeal irritating
Motor and sensory system- Normal
Reflexes - present
Cranial nerves - intact
PER ABDOMEN
Abdominal distention - Present
All quadrants are moving equally with respiration
Umbilicus - central and inverted
Scars are present, dilated veins, prominent Venous pulsations and visible pulsations.
On palpation::
Superficial palpation- No Local rise in temperature and no tenderness
Deep palpation- No guarding, rigidity
TENDERNESS - Not present
On percussion
Tympanic note - Not heard
No shifting dullness
On auscultation:
Bowel sounds heard
PROVISIONAL DIAGNOSIS
Chronic liver Disease
H/o Psoriasis
INVESTIGATIONS
#ECG
#CUE
Treatment
Inj LASIK 40 mg IV BD
Tab Spirinolactone 50 mg OD
Tab Udiliv 300 mg BD
Tab Rigagut 550 mg BD
Weight/Girth monitoring
I/O - Charting
GRBS - 6th hourly
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