45 year old male with decompensated liver disease and portal hypertension
45 year old male with decompensated liver disease and portal hypertension
May 02, 2023
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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
45 yr old male patient came with c/c of
-increased involuntary movements (tremors) ,since 1 day.
-increased drowsiness since 1 day.
History of presenting of illness- patient was apparently asymptomatic 8months back then he developed pedal edema, shortness of breath,distension of abdomen, itching of skin,jaundice and is diagnosed to have "chronic decompensated liver disease" with portal HTN with Ascites with grade 1 esophageal varcies and with HTN since 3yrs.
He was admitted in our hospital on 7/1/2023
gTreatment given was :-
1.salt restriction less than 2gm /day
2.fluid restriction less than 1.5l /day
3.Tab .lasix 40mg PO /BD for 10days
4.Tab. Spririnolactone 25mg PO /OD for 10days.
5.syrup.lactulose 15ml TID for 10days.
6.LuLitin cream l/a OD 2 weeks .
7.ebernet plus cream l/a OD 2 weeks.
8.Tab Teczine 10mg SOS.
9.absorb dusting powder thrice daily.
10days back he had shortness of breath and pedal edema and came to OPD for follow up and is on conservative management.
3days back- patient had h/o fever ,low grade ,relieved after taking medication (dolo 650mg ) not a/w cold/cough/vomiting /loose stools /pain abdomen /headache.
Increased drowsiness and involuntary movements since 1 day , aggravated with movement and relieved on taking rest
Past history -
Known case of HTN since 4 years ,n/k/c/o DM,asthma ,tb, epilepsy
h/o involuntary micturition,defecation.
Tremors - increased with movements,absent at rest.
No h/o fall,head injury,seizure activity.
Personal history:-
Diet- mixed
Appetite -narmal
Bowel and bladder movement-regular
Sleep -adequate
Addictions- chronic alcoholic
Takes 90 ml atleast twice daily
General examination:-
Patient is conscious, coherent,cooperative
Moderately built,moderately nourished
No Pallor,icterus, cyanosis, clubbing,lymphadenopathy,bilateral pedal edema
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Vitals:-
BP- 110/80mmhg
PR -85bpm
RR-20cpm
Spo2 99% at room air
GRBS - 107mg/dl
Temperature -99.4
Systemic examination:-
Cvs: s1,s2 heard ,no Murmurs,jvp not raised
Rs: BAE,no added sounds ,NVBS,
P/A: soft, distended, mild tenderness in both iliac fossa
CNS: higher mental functions intact, no focal neurological deficit
Provisional Diagnosis-
Decompensated liver disease with portal hypertension with hepatosplenomegaly with grade 2 esophageal varices with mild Portal hypertensive gastropathy with hepatic encephalopathy grade 1
Investigations:-
On 28th:-
