A 28 YEAR OLD MALE WITH ALCOHOLIC LIVER DISEASE

 

45 Goli Shreya ( 3 rd sem) 

This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission.

I have been given this case to solve in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including, history, clinical findings, investigations, and come up with a diagnosis and treatment plan.

August 06, 2021

A 28 YEAR OLD MALE WITH ALCOHOLIC LIVER DISEASE

Chief Complaint-

  A 28 year old male came to the opd with chief complaints of

• Abdominal pain and distension since 7 days
• Pedal edema extending upto knees since 7 days
• Fever since 4 days

Date of admission: 14/7/21 

HISTORY OF PRESENT ILLNESS:

# Patient was apparently asymptomatic 1 year back, then he had pain in abdomen which is of diffuse type(Not associated with vomiting).

# He stopped drinking due to the pain and got treated from local RMP for the pain.

# After the pain has subsided, ,he started to drink again. He had multiple attacks of pain in the abdomen during the past 1 year.

# Two months back he had c/o yellowish discoloration of eyes, pain in the abdomen and  b/l pedal edema for which he got treated at NIMS, his symptoms subsided within 2 days.

# Then he was tested positive for COVID-19 by RTPCR test, for which he referred to Gandhi hospital and took medication for 10 days and went back home. By that time yellowish discoloration of eyes was still present.

# One week back he had non-vegetarian food(mutton) for his dinner, and then developed pain in the abdomen, for which he got treated in the local hospital.

# There was insidious onset of Abdominal distension, pedal edema extending upto knees and Fever(Intermitent, low grade, relieved with medication) since 4 days, vomitings.

HISTORY OF PAST ILLNESS:

# Not k/c/o DM, hypertension, asthma, epilepsy, Heart disease or tuberculosis.

# He has a treatment history which has been taken for RTA which occurred twice once in 2007 and 2014, where he got treated for head injury in both the cases in 2 different hospitals.

# No treatment history for DM, hypertension, asthma, epilepsy, Heart disease or tuberculosis.

PERSONAL HISTORY:

. Appetite - lost

#non vegetarian

#Bowels - regular

#Micturation - normal

#No unknown allergies

#Alcohol - regular since past 10 yrs(180ml /day) , stopped 2 months ago

#Smoking- since past 10 yrs 1 pack of cigarette/day.

GENERAL EXAMINATION: 

Patient is conscious.

Icterus is present.

B/L Pedal edema is present.

Absence of pallor, cyanosis, clubbing, lymphadenopathy.

VITALS:

1.Temperature:- 98.4 F

2.Pulse rate: 92 beats per min

3.Respiratory rate: 24 cycles per min

4.BP: 90/50 mm Hg

5.SpO2: 98% @ Room air 

6.GRBS: 126mg% 

SYSTEMIC EXAMINATION:

CVS:

• S1,S2 heard, no cardiac murmurs. 

RS:

• Normal vesicular breath sounds.

EXAMINATION OF ABDOMEN:

• Abdomen is distended 
• No tenderness,palpeble masses
• Liver palpeble
• Spleen nt palpeble
• Bowel sounds  -yes
• Genitals - normal
• 
  

CNS:

• Conscious, speech is normal
• No focal neurological defect.

PROVISIONAL DIAGNOSIS

CHRONIC LIVER DISEASE WITH LOW GRADE VARICES nd MILD PHG.

INVESTIGATIONS:

Biochemical Investigations:

          

              CBP 

     APTT

PT

Blood urea

serum creatinine

serum electrolytes

Lft

ECG
 

TREATMEMT ::-