40 Y/ M WITH CHRONIC LIVER DISEASE
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40 year old male who is a fruit vendor , was brought to the casuality with generalised weakenss and fever since 2 days and excessive sleepiness since 2 days
HOPI:
patient was apparently asymptomatic 20 years back ,5 yrs back he was admitted in alcohol de addiction centre for 2 months and he stopped drinking alcohol for 4 months and then he again started drinking alchohol.
Now pt c/o generalised weakness and fever since 2 days and excessive sleepiness since 2 days
PAST HISTORY:
N/k/c/o DM,HTN,ASTHMA,TB,EPILEPSY,CAD
K/c/o alcoholic since 20 years
Last binge 4 days ago
PERSONAL HISTORY:
Alcoholic since 20 yrs ,daily consumption ( 90 ml)
Diet - mixed
Sleep- adequate
Bowel and Bladder movements - Regular
General Examination:
Patient is Drowsy, Coharent, co-operative
Pallor - mild
Icterus-present
Clubing-absebt
Kilonychia-absent
Lymphedenopathy- absent
Edema- absent
Febrile-100.8 F
Bp:100/80 mm hg
PR ; 112 bpm regular
Spo2: 98%@RA
SYSTEMIC EXAMINATION:
Cvs : s1 s2 +
Rs : BAE +
P/A: soft , non tender
Hepatomegaly +
INVESTIGATION:
CBP -
HB - 11.4
TLC - 7300
platelet count- 1.5 lakh
Smear - Normocytic normochromic
BGT : A + ( positive)
APTT :36 sec
PT : 17 sec
INR: 1.2 sec
RBS : 101 mg/dl
LFT :
Total bilirubin : 6.77
Direct bilirubin: 2.98
SGOT: 157
SGPT: 25
ALP : 507
ALBUMIN 3.1
TOTAL PROTEIN : 6.6
RFT :
Urea -13
creatinine- 0.6
Uric acid - 3.9
calcium- 10.2
Phosphorus- 4.0
potassium - 3.9
Sodium -136
chloride-98
HbsAg - Negative
USG ABDOMEN ( 7/3/22) :
Grade 3 fatty liver with mild hepatomegaly with mild caudate lobe hypertrophy
Mild splenomegaly with early parenchymal licer disease
ECG:
PROVISIONAL DIAGNOSIS:
Decompensated liver disease with alcohol dependence syndrome ( ? Cirrhosis with portal hypertension )
TREATMENT:
Inj. Pantop 40 mg iv /od
Inj thiamine 1 amp il
Inj zofer 4 mg iv / ns
Syrup lactulose 10 ml / po / bd
Tab rifaximin 540 mg / po/ bd
Soap water enema stat
Tab udiliv 300 mg / po / bd
Tab aldactone 25 mg /po /bd
Tab lasix 20 mg /po/ bd
Tab benxl /po/od
Mcotex gums
Tab levittacetam 500 mg /po/bd
