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
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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