36 YEAR OLD MALE PATIENT WITH YELLOWISH DISCOLORATION OF EYES AND URINE

 This is case of 36 year old male who is a master cook by occupation came to opd with complaints of yellowish discoloration of eyes 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 
        Insidious in onset 
        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

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

H/o weight loss since 1month

H/o usage of Herbal medicine 1 month back ,6 times/day for a week

H/o pedal edema and abdominal distension 1 month back , used medication for this in Nalgonda 

PAST HISTORY: 
He is a known case of alcoholic and tobacco chewers since 20 years 
H/o Renal caliculi and was operated for that .

PERSONAL HISTORY : 
Thin built 
Appetite lost 
Regular alcoholic and tobacco chewer,
stopped 3 months back 
Bowel movements are Regular

FAMILY HISTORY: Not significant

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:  LIVER PALPABLE ,No tenderness, 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.OPTINEURON 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

    APRAXIA CHARTING

DAY 3

S : 
No fever spikes 
No fresh complaints 

O : 
Pt is C/C/C 
Temp : Afebrile
BP : 100/50
PR : 80 bpm
RR : 17  cpm 
CVS : S1,S2 heard, no murmurs 
RS : NVBD + , No crepts
PA : Soft, hepatomegealy + , 22 cm liver span   
No engorged veins/ distension
GRBS : 302mg/dl 
FBS: 391mg/dl
HBA1C :  7.3% 

A : 
ACUTE DECOMPENSATED LIVER DISEASE WITH CONJUGATED HYPERBILIRUBINEMIA WITH ALCOHOLIC HEPATITIS WITH ALCOHOL INTRAHEPATIC CHOLANGITIS WITH DENOVO DM- II 

P : 
Gastroenterology opinion