27yr old with DECOMPENSATED LIVER DISEASE

 NAME : M. NAGA VARSHA 

BATCH : 2017

ADMISSION NO. 176015


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 comments on comment box is welcome.

I've 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 a diagnosis and treatment plan.

FOLLOWING IS THE VIEW OF MY CASE


Complaints of loss of appetite since 20 days

Complains of blood in urine since 10 days

Complains of pedal edema since 10 days

Complains of tremors since 15 days


HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 20 days back then he had loss of appetite for which he went to hospital and diagnosed as CLD, splenomegaly with portal hypertension and took medication. After which he complains of hematuria since 10 days and pedal edema which is pitting type, relieved on taking rest and aggravated on walking. Has tremors 15 days. Malena positive 20 days back for 10 days.


No abdominal pain, no vomitings, no burning micturition, no loose stools. 



PAST HISTORY 


not a known case of HTN,DM, TB,CVD, thyroid disorders epilepsy

H/O surgery appendectomy. 


PERSONAL HISTORY :



  1. Diet: mixed
  2. Appetite: increased
  3. Bowel habits: normal
  4. Bladder habits: normal
  5. Sleep: normal
  6. Addictions:   alcohol consumption 

      Whisky(500ml) daily          


Daily routine 


4am - wake up 

8am- 8:30am - breakfast 

1pm-3pm  - lunch

7:30pm-8:30pm - drinks alcohol 

9pm - dinner          

                            

                             

FAMILY HISTORY :


Not significant


GENERAL PHYSICAL EXAMINATION:


Patient is conscious, coherent and cooperative.

Examined after taking valid informed consent in a well enlightened room.

  • Pallor          - absent
  • Icterus        - present 
  • Clubbing    - present 
  • Lymphadenopathy    - absent
  • Cyanosis     - absent
  • Pedal edema  - present 
O/E :

Patient is c/c/c 

Temp:- 97.6  

PR-  95 bpm

BP- 100/60 mmHg

Spo2-95% at room Air 

GRBS-  75mg%

I/O - 1800/700ml

CVS- S1s2present, no murmurs heard

RS-B/L air entry present 

       N vesicular breath sounds 

PA- soft,NT

CNS - NFND
















INVESTIGATIONS: 


















PROVISIONAL DIAGNOSIS:


DECOMPENSATED LIVER DISEASE - grade 1 ( hepatic encephalopathy)

HYPOTONIC HYPONATREMIA - diuretic induced 




TREATMENT 

1. IV FLUIDS NS@ 75
2. Inj VIT K 10mg IV/STAT
3. Inj THIAMINE 200mg IV/BD in 100ml NS 
4. Syp. LACTULOSE 10ml PO/BD 
5. Strict I/O charting 
6. Vitals monitoring - 2nd hourly 

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