27 yr male with yellowish discolouration of eyes and generalised weakness

 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." 

 CHIEF COMPLAINTS 

Yellowish discolouration of eyes since 2 years  

Swelling of feet since 20 days 

Generalised weakness since 20 days 

Loss of appetite since 20 days 

Fever since 2 days 

HISTORY OF PRESENTING ILLNESS



Patient was apparently asymptomatic 2 years ago then he developed weakness  along with  loss of appetite for past few weeks with yellowish discolouration of eyes 

20 days back patient complaints of similar symptoms of generalised weakness which was insidious in onset and gradually progressive ,comparatively increased weakness from the last two episodes in past 2 years ,weakness is associated swelling of feet  confined Upto the  ankles present throughout the day ,which increases on walking and decreases while lying down or leg raising 

 No h/o chest pain ,palpitations,facial puffiness or decreased urine output 

He also had yellowish discolouration of eyes since 2 years which was gradual in onset and gradually progressive,associated with high coloured urine since 2 years , Patients complaints of darkly stained stools 20 days back only one such episode 

No h/o constipation,diarrhoea.

He also had blood in urine since 10 days and not associated with deceased urine output ,increased frequency, urgency , burning micturation,foam in the urine 

Patient complaints of low grade fever since 2 days which was insidious in onset and continuous in type and relieved only on medication 

No h/o of night sweats , chills and rigor ,myalgia ,joint pain ,rash .

Patient also complaints of increased sleepiness during the day and sleeplessness at night since 10 days 

H/o of tremors ,palpitations,fearfulness ,sweating if he stopped alcohol since 1 year 

No h/o difficulty in breathing ,orthopnea ,PND ,hematemisis  ,foul smelling breath , ,abdominal distension ,abdominal pain ,nausea ,vomitting ,loose stools .,confusion,altered sensorium 

PAST HISTORY 

Two episodes of jaundice  in the past two years for which he was taken to the hospital and declared a case of chronic liver failure .

N/k/O HTN ,DM ,TB,asthma ,heart disease ,seizures  

TREATMENT HISTORY

deaddiction medication for a week 2yrs ago

FAMILY HISTORY 

No similar complaints in the family 

PERSONAL HISTORY 

DIET -mixed 

APPETITE -decreased since 2 years 

BOWEL BLADDER - regular 

SLEEP - increased sleepiness during day time since last 20 days 

ADDICTIONS - alcoholic since 6 years consumes half a bottle everyday,non smoker. 

GENERAL PHYSICAL EXAMINATION 

Patient is conscious,coherent and co operative well oriented to time place and person ,moderately nourished and moderately built 

Pallor -absent 

Icterus -present in upper bulbar conjunctiva 




Cyanosis -absent 

Clubbing - absent

lymphadenopathy -absent 

Pedal edema - pitting type Upto ankles was present before now resolved 

VITALS

Temp 100.6F

Pulse  74/min 

Bp 110/80 mmhg

RR 17/min

SYSTEMIC EXAMINATION 

Abdomen 

Inspection 

Abdomen is scaphoid in shape  , no flank fullness 

Umbilicus has scar contracture 

No engorged veins ,sinuses 

No visible peristalsis or pulsations 

Palpation

Abdomen is non tender 

Rise  of temperature seen 

No organomegaly 

Percussion 

Upper  border of liver dullness is per used at the right 6 th inter coastal space along the mid -clavicular line on full expiration and the lower border at 5 cms below the rt costal margin 

Liver span-12 cms 

No fluid thrill 

No shifting dullness 

Auscultation

Bowel  sounds were heard 

CNS:

Conscious,coherent and cooperative 

Higher mental functions  normal
No signs of meningeal irritation. 
Cranial nerves- intact
Sensory system- normal 

Motor system:
Tone- normal
Power- bilaterally 5/5

Reflexes: Right. Left. 
Biceps. ++. ++

Triceps. ++. ++

Supinator ++. ++

Knee. ++. ++

Ankle ++. ++

CVS:

Inspection: 

Shape of chest- elliptical 
No engorged veins, scars, visible pulsations
No apical impulse seen
Palpation:
 Apex beat can be palpable in 5th inter costal space 1cm medial to mcl 
No thrills and parasternal heaves can be felt
Auscultation:
S1,S2 are heard
no murmurs

RESPIRATORY:

Inspection: 
Shape- elliptical 
B/L symmetrical , 
Both sides moving equally with respiration .
No scars, sinuses, engorged veins, pulsations 
No drooping of shoulders
No hallowing 
Trachea apppers to be central 

Palpation:
Trachea - central
Expansion of chest is symmetrical. 
Vocal fremitus - B/l normal

Percussion: 
Resonant B/l

Auscultation:
Normal vesicular breath sounds heard.

DIAGNOSIS:

Acute decompensation of liver with grade 1 hepatic enchelopathy

Investigations:

Usg: 

Ecg:











Treatment:

Iv fluids NS@75ml/ hr 

Inj thiamine 200 mg iv bd 

Tab doxy 100mg 

Tab udiliv 300mg 

Tab orofer xt 

Tab oxazepam 15 mg 

Syrup lactulose 30 ml 

Syrup hepamerz 10ml 

Fudic cream 

Comments

Popular Posts