36 YEAR OLD MALE PATIENT WITH YELLOWISH DISCOLORATION OF EYES AND URINE
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This is case of 36 year old male who is a master cook by occupation came to opd with complaints of yellowish discoloration of eyes and urine since 3 months
HOPI: patient was apparently normal 1 year back ,then he developed lower back ache ,diagnosed with renal calculi and was operated.
C/o fever since 3 months
Insidious in onset
Gradually progressive
Subsides on its own
More during nights
C/o nausea since 3 months
C/o vomitings ( 4 -5 episodes) food particles as content
C/o pain abdomen intermittently and was admitted in an hospital thrice till now and diagnosed with chronic pancreatitis
H/o usage of Herbal medicine 1 month back ,6 times/day for a week
H/o pedal edema and abdominal distension 1 month back , used medication for this in Nalgonda
He is a known case of alcoholic and tobacco chewers since 20 years
H/o Renal caliculi and was operated for that .
PERSONAL HISTORY :
Thin built
Appetite lost
Regular alcoholic and tobacco chewer,
stopped 3 months back
Bowel movements are Regular
FAMILY HISTORY: Not significant
GENERAL EXAMINATION:
ICTERUS present
NO PALLOR, CYANOSIS,CLUBBING, LYMPHADENOPATHY,EDEMA
BP: 80/60mmhg
PR: 99bpm
RR: 18CPM
SPO2: 99@room air
CVS:S1S2+ no murmurs
RS: NVBS+ clear
PER ABDOMEN:
INSPECTION: scaphoid abdomen, umbilicus inverted,no engorged veins,no sinuses
PALPATION: LIVER PALPABLE ,No tenderness, no palpable mass .
PERCUSSION:Hepatomegaly + ,LIVER span 20cm.
AUSCULTATION: Bowel sounds +
TREATMENT:
1. Inj.THIAMINE 2amp in 500ml NS/IV/TID over 2hrs
2.INJ.PANTOP 40MG/IV/OD
3.INJ.ZOFER 4MG/IV/BD
4.INJ.OPTINEURON 1amp in 100ml NS /IV/OD
5.INJ.VIT.K 1amp/IV/OD
6.INJ.MEROPENUM 1GM /IV/BD
7.TAB.DOILIN 300MG /PO/BD
8.TAB.RIFAGUT 550MG /PO/BD
9.SYRUP .LACTULOSE 10ML /PO/OD
10.SOAP WATER ENEMA
11.ABDOMINAL GIRTH MEASUREMENT
12. FEVER CHARTING
13.MONITOR VITALS
No fever spikes
No fresh complaints
O :
Pt is C/C/C
Temp : afebrile
BP : 110/50
PR : 74 bpm
RR : 20 cpm
CVS : s1 s2 heard, no murmurs
RS : NVBD + , No crepts
PA : Soft, hepatomegealy + , 22 cm liver span
No engorged veins/ distension
GRBS : 284 mg/dl
A :
ACUTE DECOMPENSATED LIVER DISEASE WITH CONJUGATED HYPERBILIRUBINEMIA
P :
1. INJ. MEROPENEM 1 GM/IV/BD ( D3 )
2. INJ. PANTOP 40 MG /IV/ OD
3. INJ. ZOFER 4 MG /IV/SOS
4. INJ. THIAMINE 2 AMP IN 500 ML NS /IV/TID
5. INJ. OPTINEURON 1 AMP IN 100 ML NS /IV OD
APRAXIA CHARTING
No fever spikes
No fresh complaints
O :
Pt is C/C/C
Temp : Afebrile
BP : 100/50
PR : 80 bpm
RR : 17 cpm
CVS : S1,S2 heard, no murmurs
RS : NVBD + , No crepts
PA : Soft, hepatomegealy + , 22 cm liver span
No engorged veins/ distension
GRBS : 302mg/dl
FBS: 391mg/dl
HBA1C : 7.3%
A :
ACUTE DECOMPENSATED LIVER DISEASE WITH CONJUGATED HYPERBILIRUBINEMIA WITH ALCOHOLIC HEPATITIS WITH ALCOHOL INTRAHEPATIC CHOLANGITIS WITH DENOVO DM- II
P :
Gastroenterology opinion
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