60 yr old male patient with c/o Giddiness.

Chief complaints:

Patient c/o giddiness since 6days

C/o headache since 6days

Hopi:

Patient was apparently sympatomatic 10 years back then he had stomach ache for which he was referred to our hospital. Then he was diagnosed with intestinal perforation and he was operated and discharged after 6 days. 


4 years ago visited hospital in view of abdominal pain, epigastric region, non radiating, not associated with vomitings, there he was diagnosed with T2DM and was prescribed
T. Gliclazide 60 mg OD

10 days ago he visited hospital for Pain abdomen epigastric region, non radiating, not associated with vomitings and was prescribed
Inj.ISOPANE insulin 20-0-15
T. B-complex
SYP. Antacid
T. Ursodeoxycholic acid 300mg BD
T. Rabeprazole 20mg + levosulpride 75 mg OD

one week back then he had vomiting 3 episodes per day for 2 days,  non projectilee nonbilious contains food particles as contents non foul smelling, 
altered sleep cycle (sleeping during day, awake at night), yellowish discoloration of eyes.

From 4 days patient developed abdominal distension, incideous oncet, gradually progressed to the current size 82 cm not associated with abdominal pain, loose stools, fever 

From 2 days patient is not having appetite and not passing stools

No H/O of Hematemesis
No H/O bulky stools, black tarry, and clay coloured.
No H/O pruritus
No H/O fever with chills
No H/O frothy urine
No H/O haematuria, oliguria
No H/O blood transfusions
No H/O tattoo marking
No H/O loss of weight

No H/O HTN, TB, Hypo/Hyperthyroidism/ Epilepsy/Asthma/COPD/ CAD/ Blood transfusions

Family history
None of the patient’s parents, siblings or first degree relatives have or 
have had similar complaints or any significant co morbidities

The CAGE assessment for alcohol dependency
C – Has never felt the need to Cut down alcohol consumption
A – Has felt Angry at others criticizing his drinking
G – never felt Guilty about excess drinking
E – drinks in the mornings (Eye-opener)

General examination
Ictrus +
There is No Pallor, cyanosis, koilonychias, 
generalised lymphadenopathy and no pedal edema.

VITALS: 
GCS E4V4M5 
Temperature 98.5'F
Pulse 80 BPM
RR 15 Cycles/min
BP 110/70 mmHg
SpO2 98% at RA











P/A Examination:
INSPECTION:
Elliptical Distention of Abdomen
Flanks- full 
Umbilicus-  everted,
Movements simultaneously with respiration
Skin over abdomen:  smooth,
No engorged veins
PALPITATION: 
Non tender
No local rosr of Temperature
No Guarding, Rigidity,
No palpable masses
No Fluid Thrill with legs extended
No visible Peristalsis.
No hepatomegaly
No splenomegaly
AUSCULATION:
Bowel Sounds feable

CVS- Normal S1 S2 heard, No murmurs.
Respiratory: Normal vesicular breath sounds, No adventitious sounds
CNS- No Facial asymmetry, all reflexes are normal

Hemogram 1 week ago
HB 12g%
TC 11,800 cells/cumm
PLT 1.78lac

RBS 1 week ago 310

Creatinine 1 week ago 0.87

S. Amylase 1 week ago 106


LFT 1 week ago
TB 4.2
DB 1.2
AST 20
ALT 25
ALP 117
TP 7.0
ALB 3.7
APTT 40 sec
PT 16.3
INR 1.3

CUE 1 week ago
ALB +
Sugar 1%
Bile salts +
Bile pigments +

Ultrasound abdomen 1 week ago
APPROX. 100 CC OF FREE FLUID NOTED IN ABDOMEN
Liver enlarged in size 19 cms with coarse echotexture.

ECG 1 week ago


DAY 1
RBS: 70mg/dl
BGT O+ positive

RFT
Blood Urea: 94 mg/dl 
S. Creatinine: 1.4 mg/dl
Na 130
K 4.4
Cl 94

Hemogram
HB 14.5
TC 26,900
MCV 85.1
PCV 39.4
MCH 31.3
MCHC 36.8
PLT 5.36
RDW 39.1
P.S NORMOCYTIC, NORMOCHROMIC with leucocytosis

ABG  SpO2 98% on RA(venous blood gas)
pH 7.38
PCo2 22.6
PaO2 35.8
HCO3 16.3
SpO2 55.6%

LFT
TB 3.79
DB 2.39
AST 77
ALT 25
ALP 225
TP 6.2
ALB 2.6
APTT 48 sec
PT 25
INR 1.8

CUE
ALB +
Sugars +
Pus cells 1-2
Epithelial cells 1-2

Serology -ve

Ultrasound abdomen
Moderate ascitis with Septation
Altered echotexture of liver

ECG


Chest X-ray

X-ray erect abdomen



DIAGNOSIS
Hepatic encephalopathy with alcoholic liver disease

Treatment
Inj. Monocef 2g IV BD 
INJ. Pan 40 IV OD
T. Rifagut 550mg RT BD
SYP. Lactulose 10 ml PO TID
T. Ursodeoxycholic acid 300 mg PO BD
Syp. Hepamez PO 10 ML BD
Inj. Vitamin K 10 mg over 10 min

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