A 38 year male patient with compaints of yellowish discolouration of eyes since 15 days,nausea and loss of appetite since 15 days,pedal edema since one week and SOB since 2-3 days.

 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 patient's clinical problems with collective current best evidence based inputs. 


This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.

Here is a case i have seen:


A 38year old male,who is a school teacher by occupation presented with complaints of yellowish discolouration of eyes since 15 days,nausea and loss of appetite since 15 days and pedal edema since 1 week.

He was apparently asymptomatic 1 year back when He had similar complaints of SOB,mild abdominal distension for which he got here.He was diagnosed with Alcoholic liver disease and was treated conservatively and discharged.Endoscopy was done then which was normal.He took medications for 1-2 weeks and stopped taking them after.He did not drink for one month and then started drinking again.He now again presented with compaints of yellowish discolouration of eyes since 15 days,nausea and loss of appetite since 15 days,pedal edema since one week and SOB since 2-3 days.

H/O weight loss present since 6 months

H/O hairfall present since 6 months


No H/o Abdominal pain,Hematemesis,malena,Vomitings,

Jaundice,oliguria,facial puffiness,altered bowel habits,chest pain,palpitations,cough,fever,Evening rise of temperature,night sweats


Not a K/C/O DM,HTN,TB,Asthma,Epilepsy,CAD,CVA

No H/O blood transfusion


NO significant family history


 H/o alcohol consumption since 10 years,consumed 2-3 beers per day for the first five years then patient started consuming around 380ml of whisky per day for the next five years.

Patient tells of increased consmuption of alcohol upto 750ml of whisky since the past 6 months on account of his financial stress. 

 H/o withdrawal symptoms present 

No H/O smoking 


O/E: 

patient is conscious,coherent and cooperative

Moderately built

Weight-85kg

Abdominal girth-111cms

Bp- 120/70 mm of Hg 

PR- 102 bpm



Icterus present 

Pedal edema present

No pallor,clubbing,cyanosis lymphadenopathy


Raised JVP SEEN


No gynaecomastia

No spider naevi

Hyperpigmentation of knuckles seen

No Terry’s nails 



CVS- S1S2 +

CNS- no focal deficit

P/A-

Distended abdomen

Umbilicus central and inverted

No engorged veins

Shifting dullness present






INVESTIGATIONS:
 







ENDOSCOPY WAS DONE ON 8-01-2021 WHICH SHOWED
 
TREATMENT:
1-T LASILACTONE(20/50) PO BD
2-T.UDILIV 300mg PO BD
3-T.INDEROL 40mg PO OD
4-T.METADOXINE 500mg PO BD
5-SYP.LACTULOSE 10ml PO/TID
10ml—10ml—10ml
6-INJ.VIT K 10mg IV OD IN 10cc NS
7-INJ.THIAMINE 100mg in 10ml NS /IV /BD
8-INJ OPTINEURON 1amp in 10cc NS/IV/OD
9-TAB LORAZEPAM 2mg PO TID 
1—1—2
10-INJ LORAZEPAM 4mg IM/SOS 
11-DAILY WEIGHT MEASUREMENT
12-DAILY ABDOMINAL GIRTH MEASUREMENT




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