36 yr old male came with complaints of yellowish discoloration of eye and urine since 3 months

 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.

Chief complaints:-

36 yr old male who is cook by occupation and came to the hospital with chief complaints of yellowish discoloration of eye and urine since 3 months.

HOPI:-

patient was apparently normal 1 year back ,then he developed lower back ache ,diagnosed with renal calculi and was operated.

C/o fever since 3 months which is Insidious in onset and Gradually progressive , Subsides on its own More during nights.                         C /o nausea since 3 months

C/o vomitings ( 4 -5 episodes) food particles as content

H/o weight loss since 1month

C/o pain abdomen intermittently and was admitted in an hospital thrice till now and diagnosed with chronic pancreatitis

H/o usage of Herbal medicine 1 month back .

H/o pedal edema and abdominal distension 1 month back , used medication and reduced on using medication.

Past history:-

He is a known case of alcoholic and tobacco chewers since 20 years 

Drinks  750 ml alcohol per day.

H/o Renal caliculi and was operated for that .

There is h/o Tuberculosis in 2012 and used medication for that. 

No h/o diabetes , hypertension,epilepsy,asthma.

Family history:-Not significant

Personal history:-

Thin built

Appetite lost

Regular alcoholic and tobacco chewer,Stopped 3 months back

Bowel movements are Regular.

Urine is high yellow colored .

GENERAL EXAMINATION:-

ICTERUS present

NO PALLOR, CYANOSIS,CLUBBING, LYMPHADENOPATHY,EDEMA.

Patient is conscious, coherent, cooperative

Temperature : 98.5°f

BP: 80/60mmhg

PR: 99bpm

RR: 18CPM

SPO2: 99@room air

CVS:S1S2+ no murmurs

RS: NVBS+ clear

PER ABDOMEN:

INSPECTION: scaphoid abdomen, umbilicus inverted,no engorged veins,no sinuses

PALPATION: There is local raise of temperature and tenderness present at the right and left hypochondrium ,and epigastric region.

LIVER PALPABLE , no palpable mass .

PERCUSSION:Hepatomegaly + ,LIVER span 20cm.

AUSCULTATION: Bowel sounds +

CNS: NAD

INVESTIGATIONS:

DIAGNOSIS: ACUTE DECOMPENSATED LIVER DISEASE

TREATMENT:

1. Inj.THIAMINE 2amp in 500ml NS/IV/TID over 2hrs

2.INJ.PANTOP 40MG/IV/OD

3.INJ.ZOFER 4MG/IV/BD

4.INJ.OPTINEUROB 1amp in 100ml NS /IV/OD

5.INJ.VIT.K 1amp/IV/OD

6.INJ.MEROPENUM 1GM /IV/BD

7.TAB.DOILIN 300MG /PO/BD

8.TAB.RIFAGUT 550MG /PO/BD

9.SYRUP .LACTULOSE 10ML /PO/OD

10.SOAP WATER ENEMA

11.ABDOMINAL GIRTH MEASUREMENT

12. FEVER CHARTING

13.MONITOR VITALS

DAY:2

S :

No fever spikes

No fresh complaints

O :

Pt is C/C/C

Temp : afebrile

BP : 110/50

PR : 74 bpm

RR : 20 cpm

CVS : s1 s2 heard, no murmurs

RS : NVBD + , No crepts

PA : Soft, hepatomegealy + , 22 cm liver span

        No engorged veins/ distension

GRBS : 284 mg/dl

A :

ACUTE DECOMPENSATED LIVER DISEASE WITH CONJUGATED HYPERBILIRUBINEMIA

P :

1. INJ. MEROPENEM 1 GM/IV/BD ( D3 )

2. INJ. PANTOP 40 MG /IV/ OD

3. INJ. ZOFER 4 MG /IV/SOS

4. INJ. THIAMINE 2 AMP IN 500 ML NS /IV/TID

5. INJ. OPTINEURON 1 AMP IN 100 ML NS /IV OD

On 21.03.22:-

Pt is C/C/C

Temp : afebrile

BP : 110/50

PR : 74 bpm

RR : 20 cpm

CVS : s1 s2 heard, no murmurs

RS : NVBD + , No crepts

PA : Soft, hepatomegealy + , 22 cm liver span

No engorged veins/ distension

GRBS : 284 mg/dl

On 22.03.22:-