27 year old male k/c/o liver failure with generalised weakness

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 CHIEF COMPLAINTS 

Yellowish discolouration of eyes since 2 years  

Swelling of feet since 20 days 

Generalised weakness since 20 days 

Loss of appetite since 20 days 

Fever since 2 days 

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 2 years ago when his mother noticed that her alcoholic son has been looking weak ,dull along with  loss of appetite for past few weeks with yellowish discolouration of eyes in view of the above mentioned , she took him to the hospital where he was given medication in view of his addiction to alcohol ,patient continued to take the medication for a week and abstained from alcohol following his visit to the hospital and later continued to consume alcohol ,this continued for next 8 months ,when he fell sick with similar symptoms of generalised weakness and fatigue ,loss of appetite for which he was again taken to the hospital ,was advised to stop consuming alcohol but patient did not follow the instructions given by the doctor 

20 days back patient complaints of similar symptoms of generalised weakness which was insidious in onset and gradually progressive ,comparatively increased weakness from the last two episodes in past 2 years ,

weakness is associated swelling of feet  confined Upto the  ankles present throughout the day ,which increases on walking and decreases while lying down or leg raising ,not associated with scrotal swelling ,no history of chest pain ,palpitations,facial puffiness or decreased urine output 

also associated with loss of appetite,

yellowish discolouration of eyes since 2 years which was gradual in onset and gradually progressive,associated with high coloured urine since 2 years , Patients complaints of darkly stained stools 20 days back only one such episode is reported not associated with constipation,diarrhoea.

blood in urine since 10 days and not associated with deceased urine output ,increased frequency, urgency , burning micturation,foam in the urine 


Patient complaints of low grade fever (100*F) since 2 days which was insidious in onset and continuous in type and relieved only on medication not associated with night sweats , chills and rigor ,evening rise of temperature.myalgia ,joint pain ,rash .

Patient also complaints of increased sleepiness during the day and sleeplessness at night since 10 days 

H/o of tremors ,palpitations,fearfulness ,sweating if he stopped alcohol since 1 year 

H/o hair loss since 2 years .

No complaints of  difficulty in breathing ,orthopnea ,PND hemetesis ,foul smelling breath ,frequent bruises ,abdominal distension ,abdominal pain ,nausea ,vomitting ,loose stools .,confusion,altered sensorium ,lack of interest in work,decreased self care hygiene 

PAST HISTORY 

Two episodes of jaundice  in the past two years for which he was taken to the hospital and declared a case of chronic liver failure .

N/k/O HTN ,DM ,TB,asthma ,heart disease ,seizures 

No history of blood transfusions,tattooing or I.v drug Abuse ,recent travel 

TREATMENT HISTORY

deaddiction medication for a week 2 years back .

Diuretics in view of pedal edema 

SURGICAL HISTORY 

patient underwent appendectomy 4 years ago .

FAMILY HISTORY 

No similar complaints in the family 

PERSONAL HISTORY 

27 year old male unmarried ,resident of miryalguda ,a labourer by occupation

Finished education till 10 standard 

Started consuming alcohol since the age of 21

Initially consumed toddy later Whiskey since last 3 years 

Usual consumption -1/2 bottle of whiskey everyday (180ml)

not a known smoker 

Not going to work since past 15 days 

DIET -mixed 

APPETITE -decreased since 2 years 

BOWEL BLADDER - regular 

SLEEP - increased sleepiness during day time since last 20 days 

ADDICTIONS - alcoholic since 6 years 

GENERAL PHYSICAL EXAMINATION 

Patient is conscious,coherent and co operative well oriented to time place and person 

patient is moderately nourished and moderately built 

Height -5’7

Weight -48kgs 

pallor -absent 

Icterus -present in upper bulbar conjunctiva 








Cyanosis -absent 

Clubbing -present (grade-2 increase in normal angle 160 * between nail bed and proximal nail fold )

lymphadenopathy -absent 

Pedal edema - pitting type Upto ankles -11/04/2023

15/04/2023

absent 

HEAD TO TOE EXAMINATION 

hair is sparse 

No parotid swelling 

Palmar erythema- absent 

Gynaecomastia -absent 

Pale coloured nails -present 

Tremors are present 

Absent spider naevi 

Petechae,outputs-absent 

abdominal scar -midline extending from umbilicus to 1cm above pubic symphysis 


VITALS

TEMP -100.6F,measured in axilla 

PULSE  - 74/min ,regular rhythm,normal character and volume ,no delays,all peripheral pulses are palpable and equal bilaterally 

BLOOD PRESSURE -110/80 mmhg measured in rt upper limb while sitting 

RR-17/min abdominothoracic 

JVP- not raised 

SYSTEMIC EXAMINATION 


Abdomen examination 

Inspection 

Abdomen is scaphoid in shape  , no flank fullness 

Umbilicus has scar contracture 

skin is normal with midline scar from umbilicus to 1cms above pubic symphysis below 

no discolouration of skin ,engorged veins ,sinuses 

No visible peristalsis or pulsations 

Hernial orifices Normal 


PALPATION 

Abdomen is non tender , with rise of temperature due to fever 

No guarding no Rigidity 

No organomegaly 

PERCUSSION 

liver 

upper border of liver dullness is per used at the right 6 th inter coastal space along the mid -clavicular line on full expiration and the lower border at 5 cms below the rt costal margin 

Liver span-12 cms 

percussion of spleen 

Castell’s method - dullness is observed in 9 th ICS of any axillary line 

No fluid thrill 

No shifting dullness 

AUSCULTATION 

bowel sounds heard 

CNS EXAMINATION 


Conscious,coherent and cooperative 
Speech- normal
No signs of meningeal irritation. 
Cranial nerves- intact
Sensory system- normal 

Motor system:
Tone- normal
Power- bilaterally 5/5
Reflexes: Right. Left. 
Biceps. ++. ++

Triceps. ++. ++

Supinator ++. ++

Knee. ++. ++

Ankle ++. ++

CARDIOVASCULAR SYSTEM:

Inspection : 
Shape of chest- elliptical 
No engorged veins, scars, visible pulsations
JVP - not raised
Palpation :
 Apex beat can be palpable in 5th inter costal space
No thrills and parasternal heaves can be felt
Auscultation : 
S1,S2 are heard
no murmurs

RESPIRATORY SYSTEM:
Inspection: 
Shape- elliptical 
B/L symmetrical , 
Both sides moving equally with respiration .
No scars, sinuses, engorged veins, pulsations 

Palpation:
Trachea - central
Expansion of chest is symmetrical. 
Vocal fremitus - normal
Percussion: resonant bilaterally 

Auscultation:
bilateral air entry present. Normal vesicular breath sounds heard.


INVESTIGATIONS 












ULTRASOUND 

fatty liver grade -1 with hepatosplenomegaly 


PROVISIONAL DIAGNOSIS 

My provisional diagnosis in this patient is acute decompensation of chronic liver disease with symptoms suggestive of portal hypertension and hepatic encephalopathy with probably due to hepatitis secondary to alcohol, viral hepatitis .

DIFFERENTIAL DIAGNOSIS 

viral hepatitis 

Toxin induced liver damage 

SOAP notes 

17/04/2023




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