45 YERS OLD MALE WITH TREMORS


Case History and Clinical Findings
45 YERS OLD MALE WAS BROUGHT TO THE CASUALITY WITH COMPLAINTS OF INCREASED
INVOLUNTARY MOVEMENTS (TREMORS) SINCE 1 DYAND INCREASED DROWSINESS SINCE
1 DAY
HOPI:
PATIENT WAS APPARENTLY ASYMPTOMATIC 8MONTHS BACK THEN HE DEVELOPED PEDAL
EDEMA ,SHORTNESS OF BREATH ,DISTENSION OF ABDOMEN,ITCHING OF SKIN ,JAUNDICE
AND IS DIAGNOSED TO HAVE CHRONIC DECOMPENSATED LIVER DISEASE WITH PORTAL
HYPERTENSION WITH ASCITES WITH GRADE1 ESOPHGEAL VARICES WITH HYPERTENSION
SINCE 3 YEARS .PATIENT WAS ON REGULAR FOLLOW UP SINCE THEN
10DAYS BACK :SHORTNESS OF BREATH ANDF PEDAL EDEMAAND CAME TO THE OPD FOR
FOLLOW UPAND IS ON CONSERVATIVE MANAGEMENT
3DAYS BACK:PATIENT HAD H/O FEVER ,LOWGRADE RELIEVED AFTER TAKING
MEDICATIONS(DOLO650MG) NOT ASSOCIATED WITH COLD/COUGH/VOMITINGS/LOOSE
STOOLS/PAIN ABDOMEN/HEADACHE
INCREASED DROWSINESS SINCE 1DAY:NO FALLS,NO HEADINJURIES, NOSEIZYRE
ACTIVITY(UPROLLING EYE BALLS/TONGUE BITE)
H/O INVOLUNTARY MICTURATION AND DEFEACATION
TREMORS INCREASES WITH MOVEMENTS AND ABSENT AT REST
HYPERTENSION SINCE 4 YEARS AND ON MEDICATION(TAB.TELMA 40MG)
PERSONAL HISTORY:
DIET-MIXED
APPETITE -NORMAL
BOWEL AND BLADDER - REGULAR
SLEEP-ADEQUATE
ADDICTIONS- REGULAR INTAKE SINE 15 YEARS ,STOPPED 6MONTHS BACK
ALLERGIES- NONE
FAMILY HISTORY:
INSIGNIFICANT
GENERAL EXAMINATION:
PATIENT IS CONSIOUS ,COHERNT ,COPERATIVE
NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY
VITALS:
TEMP-AFEBRILE
BP- 120/70MMHG
RR-18CPM
GRBS-94MG/DL
SPO2-99% AT ROOM AIR
SYSTEMIC EXAMINATION:
CVS-S1 S2 HEARD NO MURMURS
CNS-NAD
RS-BAE+ NVBS
P/A -DISTENDED,SOFT NON TENDER,NO GUARDING,NO RIGIDITY, HERNIAL ORIFICES
NORMAL
COURSE IN THE HOSPITAL-
PATIENT WAS INVESTIGATED FURTHER AND WAS TREATED CONSERVATIVELY
PSYCHIATRY OPINION WAS ALSO TAKEN AND WAS PSCHYOEDUCATED AND ADVISED
ALOCHOL ABSTINENCE.GASTROENTEROLOGIST OPINION TAKEN AND ENDOSCOPY DONE -
MILD PHG WITH GRADE 2 OESOPHAGEAL VARICES IN 2COLUMNS AND GRADE1 IN 1
COLUMN AND WAS ADVISED REGARDING LIVER TRANSPLANTATION AND THE SAME WAS
EXPLAINED TO TH PATIENT AN PATIENT ATTENDERS AND PATIENT WAS DISVHARGED IN
STABLE CONDITION
Investigation
HAEMOGRAM 28/4/23,1/5/23,2/5/23,03/05/23
HB:9.1 ,7.3, 7.2, 7.0,
TLC:15000, 11000, 8440, 7350
PLATELETS :1.0LAKHS, 98000, 1LAKH, 84000
PCV:28.2 ,22.8, 21.8,15.0
USG (28/4/23)
IMPRESSION:IRREGULAR SURFACE WITH ALTERED ECHOTEXTURE OF LIVER WITH FEW
LIENORENAL COLLATERALS
PORTAL VEIN NORMAL 13MM-PROMINENT
MINIMAL TO MILD ASCITIS
GALLBLADDER WALL EDEMATOUS
MILD SPLENOMEGALY
F/S/O: CHRONIC LIVER DISEASE
2D ECHO 28/4/23
2D ECHO
TRIVAIL TR/AR,NO MITRAL REGURGITATION
NO RWMA,NO AS/MS
GOOD LV SYSTOLIC FUNCTION
NO DIASTOLIC DYSFUNCTION
NO PAH/PE
2/5/23
PT:20SECS
INR:1.4
APTT:37SECS
Diagnosis
CHRONIC DECOMPENSATED LIVER DISEASE
PORTAL HYPERTENSION WITH HEPATOSPLENOMEGALY
GRADE1 ESOPHAGEAL VARICES
HEPATIC ENCEPHALOPATHY GRADE 1WITH WITHDRAWAL TREMORS
Treatment Given(Enter only Generic Name)
INJ.OPTINEURON 1 AMPULE IN 100 ML NS IV OD
INJ.THIAMINE 100MG IN 100ML NS IV BD
TAB.TELMA 20MG PO/OD
TAB.RIFAGUT 550MG PO/BD
TAB.UDILIV 300MG PO/BD
SYP.LACTULOSE 15ML PO TID
TAB.LASILACTONE 5/25 PO/OD
SYP. HEPAMERZ 15ML PO/BD
TAB.PROPRONOLOL 10MG PO/OD
TAB PAN 40 MG PO/OD BBF
FLUID RESTRICTION (2L/D)
SALT RESTRICTION (2G/D)
IV FLUIDS NS @ OUTPUT +30 ML/HR
INJ.VIT K 1AMP+100MLNS IV STAT
INJ.VIT K IM
Advice at Discharge
FLUID RESTRICTION (2L/D)
SALT RESTRICTION (2G/D)
AS ADIVISED BY GASTROENTEROLOGIST.
TAB.RIFAGUT 550 MG PO/BD
SYP.LACTULOSE 15ML PO TID
SYP. HEPAMERZ 15ML PO/BD
TAB PAN 40 MG PO/OD BBF
TAB.TELMA 20MG PO/OD
TAB.PROPRONOLOL 10MG PO/OD
TAB.LASILACTONE 5/25 PO/OD
OROALBUMEN POWEDER 2TABLE SPOONS IN 1 GLASS OF WATER 3TIMES A DAY.
Follow Up
REVIEW TO THE GENERAL MEDICINE OPD -78 FRIDAY 12/ 05/23 OR SOS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.


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