S.SHIVANI REDDY 116

32 yr old with CLD secondary to alcohol

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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.

A 32 year old male presented to the opd with C/O Yellowish discoluration of  eyes and passage of dark yellow coloured urine  since 1 month.

HOPI

Patient was apparently asymptomatic one month ago then he went to village for some occassion and had developed fever and was tested dengue positive and was also diagnosed to be ?liver failure ( Total bilirubin- 5gm/dl) . 3 days later after getting back from the village he was taken to miryalaguda and that his total bilirubin was 10 gm/dl for which he was given some medication and alcohol abstinance, but the patient continued drinking . He also used herbal medication for 1 week as he developed itching all over the body he stopped taking the herbal medication.

He is married for 10 years, childless didn't get tested , significant alcohol history . Starting with white liquor around the age of 15-16 years it increased to cheap liquor / whisky ,daily intake of around 180 - 360 ml . H/o alcohol abstinance 2 years back for 1 year and resumed drinking last year . H/o smoking from the age 25 years , daily used to smoke 4 cigarette s. He stopped smoking since the last 4 years .

Past history

Not a k/c/o DM , HTN, ASTHMA , EPILEPSY , TB , CAD.

PERSONAL HISTORY

Occupation - welding work in reddys laboratory.

Diet - Mixed diet 

Appetite - Normal

Bowel and bladder - Regular

Sleep - adequate 

Addictions - 

Consumes alcohol regularly around 180- 360 ml.

H/o smoking from the age 25 yrs around 4 to 5 cigarettes/ day. He stopped smoking since the last 4 years .

No significant family history.

GENERAL EXAMINATION

Patient is conscious , coherant , cooperative .

ICTERUS - present 

pallor present, cyanosis , clubbing , lymphadenopathy, edema .

VITALS 

TEMP - 98.6 F

BP - 100/70 MMHG

PR - 82/ MIN

RR - 16 /MIN 

SPO2 - 98 % ON RA.

SYSTEMIC EXAMINATION 

CVS - S1, S2 +

RS - BAE + , NVBS 

P/A -

- SHAPE OF ABDOMEN - OBESE 

- ALL QUADRANTS MOVING EQUALLY WITH  RESPIRATION.

- NO SCARS AND SINUSES 

- HERNIAL ORIFICES ARE FREE.

- Mild Hepatomegaly is present

- SPLEENOMEGALY IS PRESENT

- NO HEPATOMEGALY

- BOWEL SOUNDS +

CNS

HMF - INTACT

CRANIAL NERVES EXAMINATION - NORMAL

SENSORY SYSTEM- INTACT

MOTOR SYSTEM EXAMINATON - NORMAL 

CEREBELLAR EXAMINATION 

FINGER NOSE COORDINATION - PRESENT

KNEE HEEL COORDINATION - PRESENT 

PROVISIONAL DIAGNOSIS 

Chronic liver disease secondary to ? Alcohol

INVESTIGATIONS 

13/11/21

CBP 

HB- 10.2

TLC - 7800

PLT - 1.57

LYMPHOCYTES - 12

LFT

TB- 15.9

DB - 7.10

AST - 366

ALT - 71

ALP - 358

TP- 7.2

ALB- 3.0

A/G - 0.71

CUE 

COLOR - BROWNISH

APPERANCE - CLEAR

ALBUMIN - TRACE 

SUGARS - NIL

BILE SALTS - NIL

BILE PIGMENTS - NIL

PUS CELLS - 2-4

EPITHELIAL CELLS - 1-3

RBC - NIL

BLOOD UREA - 12 

S. CREAT- 0.5

Chest xray PA view

Ecg 13/11/21

USG ABDOMEN 13/ 11 /21

Treatment given

Tab. MVT /PO/OD

- syp.lactulose 15ml/PO/H/S

- inj. lorazepam 2c.c /IV/SOS

- IV Fluids (NS,RL,DNS) @50ml/hr