32 yr old with CLD seconday to alcohol
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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 diagnosis and treatment plan.
Unit 6 admission
Ward case
A 32 year old male presented to the opd with C/O Yellowish discoluration of eyes and passage of dark yellow coloured urine since 1 month.
HOPI
Patient was apparently asymptomatic one month ago then he went to village for some occassion and had developed fever and was tested dengue positive and was also diagnosed to be ?liver failure ( Total bilirubin- 5gm/dl) . 3 days later after getting back from the village he was taken to miryalaguda and that his total bilirubin was 10 gm/dl for which he was given some medication and alcohol abstinance, but the patient continued drinking . He also used herbal medication for 1 week as he developed itching all over the body he stopped taking the herbal medication.
He is married for 10 years, childless didn't get tested , significant alcohol history . Starting with white liquor around the age of 15-16 years it increased to cheap liquor / whisky ,daily intake of around 180 - 360 ml . H/o alcohol abstinance 2 years back for 1 year and resumed drinking last year .
H/o smoking for 4-5 years . He stopped smoking since the last 4 years .
Denies history of nausea and vomiting , pedal edema , abdominal distension .
Not a k/c/o DM , HTN, ASTHMA , EPILEPSY , TB , CAD.
PERSONAL HISTORY
Occupation - welding work in reddys laboratory.
Diet - Mixed diet
Appetite - Normal
Bowel and bladder - Regular
Sleep - adequate
Addictions -
Consumes alcohol regularly around 180- 360 ml.
H/o smoking for 4-5 years around 10-15 beedis / day. He stopped smoking since the last 4 years .
H/o chewing chaini ocassionally.
No significant family history.
GENERAL EXAMINATION
Patient is conscious , coherant , cooperative .
ICTERUS - present
No pallor, cyanosis , clubbing , lymphadenopathy, edema .
VITALS
TEMP - 98.6 F
BP - 100/70 MMHG
PR - 82/ MIN
RR - 16 /MIN
SPO2 - 98 % ON RA.
SYSTEMIC EXAMINATION
CVS - S1, S2 +
RS - BAE + , NVBS
P/A -
- SHAPE OF ABDOMEN - OBESE
- ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION.
- NO SCARS AND SINUSES
- HERNIAL ORIFICES ARE FREE.
- SPLEENOMEGALY IS PRESENT
- NO HEPATOMEGALY
- BOWEL SOUNDS +
CNS
HMF - INTACT
CRANIAL NERVES EXAMINATION - NORMAL
SENSORY SYSTEM- INTACT
MOTOR SYSTEM EXAMINATON - NORMAL
REFLEXES -
B T S K A P
R 2+ 1+ 1+ 2+ - WITHDRAWL
L 2+ 1+ 1+ 2+ - WITHDRAWL
CEREBELLAR EXAMINATION
FINGER NOSE COORDINATION - PRESENT
KNEE HEEL COORDINATION - PRESENT
PROVISIONAL DIAGNOSIS
Chronic liver disease secondary to ? Alcohol .
PSYCHIATRY REFERAL
Soap notes day 1
AMC case
S- patient was feeling better,
No fresh complaints
O-
Bp- 110/70mm hg
Pr- 80/min
Temp:97.6°F
CVS-S1,S2 +
RS- Bae+ , NVBS , clear
P/A- soft, nontender
Bs+
CNS- hmf intact
GRBS:80mg/dl
A- Chronic liver disease 2° to ? Alcohol with Alcohol withdrawal
P-
- Tab. MVT /PO/OD
- syp.lactulose 15ml/PO/H/S
- inj. lorazepam 2c.c /IV/SOS
- IV Fluids (NS,RL,DNS) @50ml/hr
- Syp. LACTULOSE 15 ML / PO / H/S
- GRBS charting 8th hourly
Soap notes day 2
AMC case
S- patient was feeling better,
No fresh complaints
O-
Bp- 110/80mm hg
Pr- 84/min
Temp:98.2°F
CVS-S1,S2 +
RS- Bae+ , NVBS , clear
P/A- soft, nontender
Bs+
CNS- hmf intact
GRBS:80mg/dl
A- Chronic liver disease 2° to ? Alcohol with Alcohol withdrawal
P-
- Tab. MVT /PO/OD
- syp.lactulose 15ml/PO/H/S
- inj. lorazepam 2c.c /IV/SOS
- IV Fluids (NS,RL,DNS) @50ml/hr
- Syp. LACTULOSE 15 ML / PO / H/S
- GRBS charting 8th hourly
Soap notes day 5
Ward case
S- patient was feeling better,
No fresh complaints
O-
Bp- 110/60mm hg
Pr- 94/min
Temp:98.2°F
CVS-S1,S2 +
RS- Bae+ , NVBS , clear
P/A- soft, nontender
Bs+
CNS- hmf intact
GRBS:110
A- Chronic liver disease 2° to ? Alcohol with Alcohol withdrawal
P-
- TAB. MVT /PO/OD
- SYP.LACTULOSE 15ml/PO/H/S
- INJ.LORAZEPAM 2c.c /IV/SOS
- IV FLUIDS (NS,RL,DNS) @50ml/hr
- INJ.THIAMINE 1 AMP IN 100 ML NS IV
- SYP. LACTULOSE 15 ML / PO / H/S
- TAB. OXAZEPAM15 MG PO BD
- GRBS charting 8th hourly
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