A 27 YR OLD MALE PATIENT CAME WITH LOSS OF APPETITE


Case History and Clinical Findings
PATIENT CAME WITH C/O LOSS OF APPETITE SINCE 20 DAYS, TREMORS SINCE 15 DAYS,
BLOOD IN URINE SINCE 10 DAYS, PEDAL EDEMA SINCE 10 DAYS.
HISTORY OF PRESENTING ILLNESS: PATIENT WAS APPARENTLY ASYMPTOMATIC 20 DAYS
BACK THEN HE HAD LOSS OF APPETITE FOR WHICH HE WENT TO HOSPITAL AND WAS
DIAGNOSED AS CLD, SPLENOMEGALY WITH PORTAL HYPERTENSION AND TOOK
MEDICATION. AFTER THAT, HE COMPLAINED OF HEMATURIA FOR 10 DAYS AND PEDAL
EDEMA WHICH IS PITTING TYPE. PEDAL EDEMA IS RELIEVED BY TAKING REST AND
INCREASED ON WALKING. HE C/O TREMORS SINCE 10 DAYS. MELENA POSITIVE 20 DAYS
BACK FOR 10 DAYS. C/O DECREASED SLEEP SINCE 1 MONTH.
NO ABDOMINAL PAIN, NO VOMITINGS, NO LOOSE STOOLS, NO BURNING MICTURITION.
PAST HISTORY: SIMILAR COMPLAINTS 1 YEAR BACK.
N/K/C/O DM 2 ,HTN,TB,EPILEPSY ,CVA,CAD
PERSONAL HISTORY:
TAKES MIXED DIET, WITH DECREASED APPETITE
ADDICTIONS- ALCOHOLIC SINCE 6 YEARS,INCREASED INTAKE SINCE 2 YEARS (HALF
BOTTLE )
O/E:
PATIENT IS C/C/C
NO SIGNS OF PALLOR,CYANOSIS,LYMPHADENOPATHY
ICTERUS +, CLUBBING +,OEDEMA OF FEET +
VITALS
TEMP:97.6F
PR: 95 BPM
BP: 100/60 MMHG
RR: 14 CPM
CVS: S1S2+ HEARD, NO MURMURS
R/S: BAE +
P/A: SOFT, NON TENDER
CNS: NFND
COURSE IN THE HOSPITAL :
PATIENT CAME TO THE HOSPITAL WITH ABOVE MENTIONED COMPLAINTS.THERE WAS A
FEVER SPIKE ON 13/4/2023 AND SUBSIDED WITH MEDICATION.PSYCHIATRY REFERRAL
WAS DONE I/V/O ALCOHOL DEPENDENCE WAS AND THE ADVICE WAS FOLLOWED.
DERMATOLOGY REFERRAL WAS DONE I/V/O CORNS AND SURGICAL PARING WAS DONE
FOR THE SAME. PATIENT WAS TREATED FOR THE ABOVE COMPLAINTS ACCORDINGLY AND
THE SYMPTOMS SUBSIDED.
Investigation
HEMOGRAM DONE ON 12/4/2023
HB-8.5GM/DL
TLC-16,100
PCV-25.9VOL%
RBC COUNT-2.6MILLIONS/CUMM
PLT-2.9 LAKHS/CUMM
NORMOCYTIC NORMOCHROMIC ANEMIA WITH NEUTROPHILIC LEUCOCYTOSIS
USG ABDOMEN DONE ON 12/4/2023
GRADE 1 FATTY LIVER WITH MILD HEPATOSPLENOMEGALY
Diagnosis
1) DECOMPENSATED LIVER DISEASE
2) GRADE 1 HEPATIC ENCEPHALOPATHY (RESOLVED)
3) ANEMIA ? IDA
4) HYPOTONIC HYPONATREMIA ?DIURETIC INDUCED (RESOLVED)
5) ALCOHOL DEPENDENCE SYNDROME
6) CORN (SURGICAL PARING DONE OVER PLANTAR ASPECT OF BIG TOES- 15/4/23)
Treatment Given(Enter only Generic Name)
IV FLUIDS NS @75ML/HR
INJ.VIT K 10MG IV/OD
INJ.THIAMINE 200MG IV/BD
TAB.DOXY 100MG PO/BD
TAB.UDILIV 300MG PO/BD
SYP.HEPAMERZ 10ML PO/TID
SYP.LACTULOSE 10ML PO/BD
TAB.OROFER XT PO/OD
TAB.OXAZEPAM 15MG PO HS
Advice at Discharge
TAB.UDILIV 300MG PO/BD X 1 WEEK
SYP.HEPAMERZ 10ML PO/TID X 1 WEEK
TAB.OROFER XT PO/OD X 1 MONTH
TAB.OXAZEPAM 15MG 1 TABLET PO/HS X 5 DAYS
SYP.LACTULOSE 30ML PO/TID X 1 WEEK
FUDIC CREAM FOR L/A X 2 WEEKS
PROTEIN X POWDER 2 TBSP IN 1 GLASS OF MILK/WATER
2 EGG WHITES PER DAY
Follow Up
REVIEW AFTER 1 WEEK TO GENERAL MEDICINE OPD OR REVIEW SOS.
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT




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