53 M WITH DECOMPENSATED ALCOHOLICLIVER DISEASE WITH PORTAL HYPERTENSION WITHTHROMBOCYTOPENIA

 Hi, I am J. Harsha Vardhan Foreign Medical Graduate . This is an E-Log, that depicts the patient centered approach for learning medicine .This E-Log has been created after taking consent from the patient and their relatives. The links that were used by me for understanding the available data on the particular disease have been mentioned below in each post . Hope you learn valuable information after giving it a good read!

CHIEF COMPLAINT 

This is a case of a 53-year-old male, a Hotel owner and chief by occupation,

The patient presented to the hospital with chief complaints of

• Swelling of both Legs since 20 days
• Swelling of face since 7 days
• Decrease intake of food since 20 days

HISTORY OF PRESENTING ILLNESS 

The patient was apparently asymptomatic 20 days ago.

Then he developed Bilateral Pedal odema which is pitting type extending up to the knee, insidious in gradually progressive , since one week  

Patient has decreased urine output since 10 days not associated with burning micturation 

• yellowish discolouration of urine
• constipation since 15 days 

No c/o - Chest pain, Palpitations , Shortness of breath ,Orthopnea, PND

No c/o - Fever , Vomitings , loose stools.

Not K/N/C- Hypertension, Epilepsy, Thyroid disorders.

K/C/O - Chronic Alcoholic since 20 yrs , every day consumption around 360 ml 

Last consumption 1 week back.

PAST HISTORY 

• Patient was diagnosed with Poliomyelitis of upper limb and lower limb of left side in his early childhood age .
• No past surgical history 

FAMILY HISTORY 

Patient was born to Congenious parents and was bought up in joint family house along with his other siblings. his father owns a farm lands which was divided among his father’s brother.

Patient was in good terms with his parents up to certain period of time.

Later than he has separated from then and use to live along with his wife parents in their house.after some years he moved out from his native place to another place along with his wife.

PERSONAL HISTORY 

• Appetite - Decreased for the past 7 days. 
• No Burning Micturation is present for the past 7 days  
• Constipation for 3-4 days with every episode
• Sleep - adequate 
• Diet - Non-Veg & Mixed (Veg) sometimes 
• Chronic Alcoholic since 20 years
• No allergies 

Marital status-married twice 

Patient had married twice. With his first wife he has 2 sons 1 daughter .

due to miss understandings between both husband and wife they decided to separate and got separated and he got married to another women . but his parents were not happy with their separation and didn’t allow his 2nd wife to enter their home.

After all familial fight with his parents and his 1st wife, he decided to leave his home and moved into his 2nd wife home and he has 2 daughters with is 2nd wife to. 

Due to this familial separation and fight among them he lost his father farm lands.

Which made him to suffer lot of financial trouble.

OCCUPATIONAL HISTORY 

Previously was a farmer in his farm land which was given to him before his 2nd marriage  later he moved from his 2nd wife place to another city and started his own Hotel .

He's an alcoholic addict since 20yrs who use drink weekly but gradually it has become daily habit, he's everyday consumption was about 360ml since few months

• Wakes up 6 am gets fresh up .
• 7am and goes to hotel and starts cooking
• 8am along with drinking alcohol and continues his work again he starts drinking 11:30am. 
• 2pm - he takes lunch and sleeps till 5pm up get fresh up & start drinking 7pm . 
• Eats dinner at 8 and sleeps around 9 to 10.

GENERAL EXAMINATION

Patient was conscious ,non-coherent , cooperative ,well built and nourished not so well oriented to time place & person at the time of presentation.

Pallor- present

Icterus-present

Cyanosis-absent 

Clubbing-present 

Lymphadenopathy-absent

Edema -present b/l pitting type .

VITALS

Temperature-97.6'f 

Pulse rate -90bpm.

Bp-150/80mm hg 

RR-17cpm 

Spo2-99% . 

grbs-110mg/

                  

Abdomen examination 

INSPECTION:-

Shape of abdomen -distended 

Umbilicus-inverted.

No scars ,sinuses,straie

No visible pulsations & visible peristalsis.

Moments of all 4quadrants moving equally with respiration

                                                               Abdominal Distension

                                       

                                           

    

                                                            

                        

                          Ecchymosis on Left shoulder

     

                              Icterus present

          

                            Bilateral Pitting Oedema

          

Percussion:-

Shifting dullness-+

No signs of fluid thrill.

CVS:-

S1,S2heard ,no murmurs.

CNS :-

Higher motor functions - intact

Cranial nerves - intact

Motor system: 

Power :      Rt-UL   LL.          Lt -UL   LL

                   5/5    5/5.               5/5   5/5   

Hand grip.   100%.                      0%

Reflexes:

                          UL.                               LL

Biceps.                 2+.                               +2

Triceps.                 2+.                              +2

Supinator.              0                                   0

Knee                      0                                  2+

ankle jerk cannot be seen due to pedal edema?                                                                                   Sensory system: intact

Cerebellar functions are normal

Respiratory examination:- 

Trachea is central 

Chest moments -normal 

Bae-+

Investigation

09.06.2023 - 10.06.2023

11.06.2023

    

                        U.S.G impressions

ECG

Chest X-ray

12.06.2023

13.06.2023

Ascitic Fluid

Volume-3ml

Colour-clear

Rbc-nil

Tc-50

Dc-100

Others nil

Upper GI Endoscopy (13.06.2023)

Esophagus : Grade -1 Esophageal varices (2 columns)

Stomach : Severe PHG ( portal hypertension gastropathy)

Duodenum: D1 D2 normal

Impression : Severe PHG with Grade -1 Esophageal varices 

PROVISIONAL DIAGNOSIS:

DECOMPENSATED CHRONIC LIVER DISEASE WITH PORTAL HYPERTENSION  (SPLENOMEGALY,MODERATE ASCITIS) WITH THROMBOCYTOPENIA SECONDARY TO CLD ? B12 DEFICIENCY WITH ALCOHOL WITHDRAWAL STATE.

Treatment 

Fluid restriction <2l /day 

Injection - vitk IV/ OD ( 1Amp in 100 ml NS)

CAP-evion 400mg PO/OD

Tab- Benfothiamine 100mg PO/ TID 

Tab UDILIV 300mg PO/BD 

Tab Lorazepam 2mg 1-1-2

Tab Baclofen 20mg OD(HS)

Tab Aldactone 50mg  OD 2pm

Syrup-lactulose 15ml / PO/ BD  

Salt restriction <2l/day 

Protein rich diet (2egg white/day)