A 32 years male patient with yellowish discoloration of eyes


Case History and Clinical Findings
A 32 years male patient driver by occupation came to casuality with chief complaints of abdominal
distention, pedal edema since 10 days and yellowish discoloration of eyes since 20 days
HISTORY OF PRESENT ILLNESS :-
Patient was apparently asymptomatic 20 years ago and at the age of 10, patient developed one
episode of seizure for which he did not use any medication and seizures subsided by itself.
About 10 years ago the patient had developed scaly lesions over the legs and hands for which he had
diagnosed asPsoriasisand since then he was on medication.
About one year ago patient developed yellowish discoloration of eyes for which he used herbal
medication for about six days. Again after three months patient developed similar
complaints(Yellowish discoloration of eyes) for which he used herbal medication for about seven
days.
Now, since 20 days patient is having yellowish discoloration of sclera and distention of abdomen and
pedal edema since 10 days.
PAST HISTORY:
Patient is a known case on pulmonary hypertension and he is on medication.
Patient is not a known case of diabetes, tuberculosis,asthma, epilepsy.
PERSONAL HISTORY:
Diet - mixed
Appetite-Decreased
Bowel and Bladder movements-Regular with burning micturition
Sleep- adequate
Addictions
Alcohol intake around 180 ml since 7yrs '' daily
Occasional smoker
ON EXAMINATION:
Patient was conscious, coherent, cooperative and we'll oriented to time place and person
GENERAL PHYSICAL EXAMINATION:
Pallor-Present
Icterus- Present
Cyanosis- Absent
Clubbing- Absent
Generalized lymphadenopathy- Absent
Vitals
Temperature- Afebrile
Pulse rate -90bpm
Respiratory rate - 16cpm
Blood pressure-120/70mmHg
sPo2 98% at room temperature
SYSTEMIC EXAMINATION :
CVS: Inspection
Chest wall is bilaterally symmetrical.
No precordial bulge is seen
Palpation
JVP- Normal
Apex beat -felt in the left 5th intercoastal space in the mid clavicular line
Auscultation
S1&S2 are heard,no murmur found.
RESPIRATORY SYSTEM
Position of trachea- central
Bilateral air entry, normal vesicular breath sounds are heard.
No added sounds
CNS Examination
Patient is conscious coherent and well oriented towards time.
Speech is normal
No signs of meningeal irritating
Motor and sensory system- Normal
Reflexes - present
Cranial nerves - intact
PER ABDOMEN
Abdominal distention - Present
All quadrants are moving equally with respiration
Umbilicus - central and inverted
Scars are present, dilated veins, prominent Venous pulsations and visible pulsations.
On palpation::
Superficial palpation- No Local rise in temperature and no tenderness
Deep palpation- No guarding, rigidity
TENDERNESS - Not present
On percussion
Tympanic note - Not heard
No shifting dullness
On auscultation:
Bowel sounds heard.
COURSE IN THE HOSPITAL :
PT WAS ADMITTED AND INVESTIONS WERE SENT ,I/V/O DERANGED LFT PT DIAGNOSED
WITH CHRONIC LIVER DISEASE .USG GUIDED DIAGNOSTIC TAP WAS DONE .OPHTHAL
OPINION WAS TAKEN I/V/O KF RING AND NO KF RING SEEN. DERMA OPINION WAS TAKEN
I/V/O H/O PSORIASIS AND ACNE ALL OVER BODY, DIAGNOSED ? LICHENOID DRUG
ERUPTION WITH ACNEIFORM ERUPTION AND TREATED CONSERVATIVELY.
Investigation
USG ABDOMEN :
MODERATE TO GROSS ASCITIES
GB WALL EDEMA
ALTERED ECHOTEXTURE WITH IRREGULAR SURFACE OF LIVER WITH MESENTERIC
COLLATERALS
ENDOSCOPPY WAS DONE ON 2-8-22 LOW GRADE ESOPHAGEAL VARICES PRESENT
Diagnosis
ACUTE ON CHRONIC LIVER DISEASE 

Treatment Given(Enter only Generic Name)
1.TAB LASIX 40MG PO/TID
2.TAB.SPIRONOLACTONE 100MG PO/OD
3.TAB .UDILIV 300MG PO/BD
4.SYP.LACTULOSE 30ML PO/HS
5.TAB .RIFAGUT 550MG PO/BD
6.TAB PANTOP 40MG PO/OD
7.BENZAC AC GEL L/A FACE 2WEEKS
8.MOISTUREX SOFT LOTION BODY 2 WEEKS
9.E /D LUMBREX 5 TIMES /DAY
9.PROTEIN POWDER IN 100ML MILK PO /OD
Advice at Discharge
1.TAB LASIX 40MG PO/TID
2.TAB.SPIRONOLACTONE 100MG PO/OD
3.TAB .UDILIV 300MG PO/BD
4.SYP.LACTULOSE 30ML PO/HS
5.TAB .RIFAGUT 550MG PO/BD
6.TAB PANTOP 40MG PO/OD
7.BENZAC AC GEL L/A FACE 2WEEKS
8.MOISTUREX SOFT LOTION BODY 2 WEEKS
9.PROTEIN POWDER IN 100ML MILK PO /OD
10.TAB .VIBOLIV 500MG PO/BD
11.TAB MYXILIV 500MG PO/BD
12.TAB ANTIOXID PO/OD
13TAB PREDNISALONE 20 MG PO OD(STARTED ON 30-7-22) FOR ONE WEEK
TAB PREDNISALONE 10MG PO OD FOR ON WEEK
TAB PREDNISALONE 5MG PO OD FOR 1 WEEK AND STOP
REFFERRED TO HIGHER CENTER IN V/O ESOPHAGEAL VARICES AND HEMETEMESIS FOR
GASTROENTEROLOGIST OPINION FOR FURTHER MANAGEMENT
Follow Up
REVIEW TO GASTRO OPD FOR ENDOSCOPY ON NBM WAS DONE GRADE 2 ESOPHAGEAL
VARICES
LOW GRADE ESOPHAGEAL VARICES
REVIEW AT GM OP AFTER 2 WEEKS WITH ANA PROFILE INVESTIGATIONS REPORTS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.

Comments

Post a Comment

Popular posts from this blog

A 55year old female with h/o seizures

Image
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have 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 diagnosis and treatment plan. This blog is done by 103.Pavan.Ch & 104.Jeshmitha.P A 55yr old female resident of chityal with history of seizures  Chief complaints:- The patient was brought to casuality with cheif complaints of Active in
Read more

OSCE PREFINAL EXAMINATION

Image
OSCE PREFINAL EXAMINATION Date :2/12/ 2023 A 55yr old female resident of chityal with history of seizures  Chief complaints:- The patient was brought to casuality with cheif complaints of Active involuntary movements ,since 30 minutes, history of frothing from mouth deviation of eyeball upwards ,toungue bite with urinary incontinance no h/o of fever, head injury, vomitings, loose stools. History of presenting illness - asymptomatic 20 yrs ago  she developed sudden onset of movements in upper and lower limbs for 5 minutes , confusion  The frequency & duration  of episodes were gradually increasing with in these 20 years  Initially it was 1 episode in 5 yrs ---->later 2-3 episodes within 5yrs ----->one episode in 2years ---> single episode in 1yr ---->2-3 episode in a year  PHENYTOIN -100mg OD was prescribed in a private hospital  She was on underdosage of phenytoin  (phenytoin maintainence dose is usually 100mg thrice a day - 3-5mg/kg/day) Even For which she noticed sid
Read more

CLINICAL E LOG GENRAL MED .

BIMONTHLY BLENDED ASSESSMENT - August 2021 - Aug 24 , 2021 BIMONTHLY BLENDED ASSESSMENT - August  2021 —104. JESHMITHA PERUMALLA  https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006003-case-presentations.html?m=1   Q1) (Testing peer review competency in the active reader of this assignment) : Please go through the long and short cases in the first link shared above and provide your critical appraisal of the captured data in terms of completeness, correctness and ability to provide useful leads to analyze the diagnostic and therapeutic uncertainties around the cases shared. Please provide your peer review assessment on not only the the student's written case report but also the reading of the cases followed by the question answer session linked above in the video and share your thoughts around each answer by the student along with your qualitative insights into what was good or bad about the answer.  Answer 1: critical appraisal and qualitative insights about the prov
Read more