44YEAR OLD MALE PATIENT WITH JAUNDICE

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August 15, 2021

A 44YEAR OLD MALE PATIENT WITH JAUNDICE

 A 44year Old male patient,engineer by occupation came to the opd with the chief complaints of 

-bilateral pedal Edema since 20 days extending upto the knees

-yellowish discolouration of sclera and skin since 20days

-vomitings since 1week for about 2-3 episodes a day 

History of presenting illness-

Patient  was apparently asymptomatic 20 days back and then gradually developed  Bilateral pedal edema putting type extending upto knees since 20days along with yellowish discolouration of sclera and skin since 20days.

Patient gives a history of yellowish discolouration of sclera since 1year which developed Gradually and resolved on Tab.UDILIV and Tab.LIV-52mg

He has been experiencing 2-3episodes of non-projectile vomitings with food as content,non-bilious,non-blood stained vomitings since 1week .

No h/o pain abdomen, abdominal distension , Malena ,loose stools , fever

Treatment history 

• Yellowish discolouration of sclera since 1yr which is resolved with Tab.UDILIV ,TAB LIV 52mg. 

Personal History

• Married

• Farmer by occupation 

• Appetite has decreased 

• Nonvegetarian

• Bowel and bladder movements-regular and normal 

• Micturition normal

• No H/o allergies 

Consumes 90ml whiskey 4times a day since 5months due to alcoholism since 10yrs.

Family History

• Has no family history of DM, HTN, asthma, TB, CAD, strokes, cancers, heart diseases. 

Vitals

PR- 82bpm

BP-110/70mmHg

Sp o2%-98%

GRBS-174mg%

General examination

• Consious ,coherent and cooperative

• pallor present 

• No cyanosis

• No icterus

• No clubbing

• No lymphadenopathy 

• B/l pedal edema 

• No malnutrition 

• No dehydration

Pallor+

Systemic examination 

A. Cardiovascular system :

• S1, S2 are heard

• No thrills and no cardiac murmurs

B. Respiratory system:

• No dyspnoea, no wheezing

• Position of trachea - central

• Breath sounds - Vesicular

• Crypts over left inferior and anterior area heard

C.Per Abdominal Examination:soft

• Shape of abdomen - obese

• No Tenderness 

• No palpable mass , free fluids, bruits

• Liver, spleen not palpable

•  Bowel sounds-present

D. Central Nervous system Examination:

• Pt is conscious

• Speech normal

• No neck stiffness, kerning's sign. 

NFND

 

INVESTIGATIONS- 

13/8/21

USG abdomen

Hemogram

Prothrombin time

bleeding and clotting time

LFT

APTT

RFT

14/8/21

Complete urine examination

2d echo

Ecg

HBsAg Rapid

HIV RAPID TEST

Provisional diagnosis

Alcoholic hepatitis 

Treatment given-

Day-1

Soap notes

13/8/21

Vitals-

Temperature-97 F

Bp-120/80 mm/hg

PR- 76bpm

RR -17 cpm

Grbs-124 mg/dl

• Inj.THIAMINE 1amp in 100ml NS -IV TID

• Inj.Pantop 40mg IV -OD

• Inj. ZOFER 4mg IV TID

• TAB.UDILIV 300mg BD

• Tab.lasilactone 20/50mg BD

• Bp/ PR /Temp/Spo2 monitoring 

Day-2

14/8/21-soap notes 

Vitals-

OBJECTIVE

Temperature-97 F

Bp-110/60 mmhg

PR- 86bpm

RR -17 cpm

Grbs-144 mg/dl

• Inj.THIAMINE 1amp in 100ml NS -IV TID

• Tab.Pantop 40mg IV -OD

• TAB.UDILIV 300mg BD

• Tab.Viboliv 500mg TID

Tab.prednisolone 40 mg OD

• Bp/ PR /Temp/Spo2 monitoring 

Day-3-

15/8/21-soap notes 

Vitals-

OBJECTIVE

Temperature-97F

Bp-110/60 mmhg

PR- 80bpm

RR -16cpm

Grbs-98 mg/dl

• Inj.THIAMINE 1amp in 100ml NS -IV TID

• Tab.Pantop 40mg IV -OD

• TAB.UDILIV 300mg BD

• Tab.Viboliv 500mg TID

• Tab.Pentoxifylline 400mg TID

Tab.prednisolone 40 mg OD

• Bp/ PR /Temp/Spo2 monitoring

16/8/2021- soap notes 

Patient has no new complaints 

Vitals-

OBJECTIVE

Temperature-97F

Bp-120/80mmhg

PR- 96bpm

RR -16cpm

Grbs-122mg/dl

• Inj.THIAMINE 1amp in 100ml NS -IV TID

• Tab.Pantop 40mg IV -OD

• TAB.UDILIV 300mg BD

• Tab.Viboliv 500mg TID

• Tab.Pentoxifylline 400mg TID

Tab.prednisolone 40 mg OD

• Bp/ PR /Temp/Spo2 monitoring