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

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.




This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.




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  











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:- 

















On 29/4/23




On 30/4/23








On 1/5/23





2/5/23






3/5/23







Treatment:- 

Fluid restriction<2l/day 

Salt restriction<2g/day 

As adviced by gastroenterologist 

Tab Rifagut 550 mg po/od 

Syp Hepamerz 15ml po/od 

Tab lasilactone 5/25 po/od 

Syp lactulose 15ml/po/tid 

Tab Telma 20mg po/od

Tab Propranolol 10mgpo/od

Tab pan 40mg /po/od bbf

Oroalbumen powder 2 table spoons in 1 glass of water 3 times a day  

Gastroenterologist opinion





Psychiatrist opinion 








Discharge summary:-  

Diagnosis -

Decompensated liver disease with portal hypertension with hepatosplenomegaly with grade 2 esophageal varices with mild Portal hypertensive gastropathy with hepatic encephalopathy grade 1  

Course in hospital:-

Patient was further investigated  was treated  conservatively  psychiatry opinion was taken and was psycho educated and advised alcohol abstinence.Gastroenterologist opinion was  taken and endoscopy was done.Mild PHG with 2nd grade  esophageal varices  in 2 column and was advised  regarding liver transplantion and the same was explained  to the patient an patient attenders. 

Treatment:-

Fluid restriction<2l/day 

Salt restriction<2g/day 

As adviced by gastroenterologist 

Tab Rifagut 550 mg po/od 

Syp Hepamerz 15ml po/od 

Tab lasilactone 5/25 po/od 

Syp lactulose 15ml/po/tid 

Tab Telma 20mg po/od

Tab Propranolol 10mgpo/od

Tab pan 40mg /po/od bbf





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