A 44year Old male patient,engineer by occupation came to the opd with the chief complaints of
-bilateral pedal Edema since 20 days extending upto the knees
-yellowish discolouration of sclera and skin since 20days
-vomitings since 1week for about 2-3 episodes a day
History of presenting illness-
Patient was apparently asymptomatic 20 days back and then gradually developed Bilateral pedal edema putting type extending upto knees since 20days along with yellowish discolouration of sclera and skin since 20days.
Patient gives a history of yellowish discolouration of sclera since 1year which developed Gradually and resolved on Tab.UDILIV and Tab.LIV-52mg
He has been experiencing 2-3episodes of non-projectile vomitings with food as content,non-bilious,non-blood stained vomitings since 1week .
No h/o pain abdomen, abdominal distension , Malena ,loose stools , fever
Treatment history
• Yellowish discolouration of sclera since 1yr which is resolved with Tab.UDILIV ,TAB LIV 52mg.
Personal History
• Married
• Farmer by occupation
• Appetite has decreased
• Nonvegetarian
• Bowel and bladder movements-regular and normal
• Micturition normal
• No H/o allergies
Consumes 90ml whiskey 4times a day since 5months due to alcoholism since 10yrs.
Family History
• Has no family history of DM, HTN, asthma, TB, CAD, strokes, cancers, heart diseases.
Vitals
PR- 82bpm
BP-110/70mmHg
Sp o2%-98%
GRBS-174mg%
General examination
• Consious ,coherent and cooperative
• pallor present
• No cyanosis
• No icterus
• No clubbing
• No lymphadenopathy
• B/l pedal edema
• No malnutrition
• No dehydration
Pallor+
Systemic examination
A. Cardiovascular system :
• S1, S2 are heard
• No thrills and no cardiac murmurs
B. Respiratory system:
• No dyspnoea, no wheezing
• Position of trachea - central
• Breath sounds - Vesicular
• Crypts over left inferior and anterior area heard
C.Per Abdominal Examination:soft
• Shape of abdomen - obese
• No Tenderness
• No palpable mass , free fluids, bruits
• Liver, spleen not palpable
• Bowel sounds-present
D. Central Nervous system Examination:
• Pt is conscious
• Speech normal
• No neck stiffness, kerning's sign.
NFND
INVESTIGATIONS-
13/8/21
USG abdomen
Hemogram
Prothrombin time
bleeding and clotting time 14/8/21
Complete urine examination
2d echo
Provisional diagnosis
Alcoholic hepatitis
Treatment given-
Day-1
Soap notes
13/8/21
Vitals-
Temperature-97 F
Bp-120/80 mm/hg
PR- 76bpm
RR -17 cpm
Grbs-124 mg/dl
• Inj.THIAMINE 1amp in 100ml NS -IV TID
• Inj.Pantop 40mg IV -OD
• Inj. ZOFER 4mg IV TID
• TAB.UDILIV 300mg BD
• Tab.lasilactone 20/50mg BD
• Bp/ PR /Temp/Spo2 monitoring
Day-2
14/8/21-soap notes
Temperature-97 F
Bp-110/60 mmhg
PR- 86bpm
RR -17 cpm
Grbs-144 mg/dl
• Inj.THIAMINE 1amp in 100ml NS -IV TID
• Tab.Pantop 40mg IV -OD
• TAB.UDILIV 300mg BD
• Tab.Viboliv 500mg TID
Tab.prednisolone 40 mg OD
• Bp/ PR /Temp/Spo2 monitoring
Day-3-
15/8/21-soap notes
Temperature-97F
Bp-110/60 mmhg
PR- 80bpm
RR -16cpm
Grbs-98 mg/dl
• Inj.THIAMINE 1amp in 100ml NS -IV TID
• Tab.Pantop 40mg IV -OD
• TAB.UDILIV 300mg BD
• Tab.Viboliv 500mg TID
• Tab.Pentoxifylline 400mg TID
Tab.prednisolone 40 mg OD
• Bp/ PR /Temp/Spo2 monitoring
16/8/2021- soap notes
Patient has no new complaints
Temperature-97F
Bp-120/80mmhg
PR- 96bpm
RR -16cpm
Grbs-122mg/dl
• Inj.THIAMINE 1amp in 100ml NS -IV TID
• Tab.Pantop 40mg IV -OD
• TAB.UDILIV 300mg BD
• Tab.Viboliv 500mg TID
• Tab.Pentoxifylline 400mg TID
Tab.prednisolone 40 mg OD
• Bp/ PR /Temp/Spo2 monitoring
Discharge summary-
Diagnosis-ALCOHOLIC HEPATITIS
Discharge Date
Date:16-08-2021
Ward: AMC
Unit: 5
Name of Treating Faculty
DR BHAVYA SREE (INTERN)
DR ABHIMANYU (INTERN)
DR RAAGA MEGHANA (INTERN) DR SAI DEEPIKA (INTERN)
DR NIKHILESH KRISHNA (INTERN) DR VAMSI KRISHNA PGY1
DR RASHMITHA PGY2
DR NIKITHA PGY2
DR HAREEN (SR)
DR ARJUN KUMAR (AP)
DR RAKESH BISWAS (HOD)
Diagnosis
ALCOHOLIC HEPATITIS
Case History and Clinical Findings
B/L PEDAL EDEMA PITTING TYPE SINCE 20 DAYS EXTENTNDING UPTO KNEES, YELLOWISH DISCOLOURATION OF SCLERA AND SKIN SINCE 20 DAYS, HIGH COLOURED URINE SINCE 20 DAYS, VOMITING SINCE 1 WEEK.
HOPI - PATIENT WAS APPARENTLY ASYMPTOMATIC 20 DAYS AGO AND THEN HE DEVELOPED
B/L PEDAL EDEMA EXTENDING UPTO KNEES SINCE 20 DAYS ALONG WITH DISCOLOURATION OF SCLERA AND SKIN SINCE 20 DAYS.
PATIENT GIVES A HISTORY OF YELLOWISH DISCOLOURATION OF SCLERA 1 YEAR BACK WHICH GRADUALLY RESOLOVED ON USING T. UDILIV, T. LIV 52MG
VOMITINGS SINCE 1 WEEK 2-3 EPISODES PER DAY, NON PRJECTILE, FOOD AS CONTENT, NON BILIOUS, NON BLOOD PINCHED.
PAST HISTORY - NO SIGNIFICANT PAST HISTORY. NO H/O DM, HTN, CAD, ASTHMA OR TB.
PERSONAL HISTORY - DIET - MIXED
APPETITE - REDUCED
BOWEL AND BLADDER - REGULAR
SLEEP - ADEQUATE
ADDICTIONS - ALCOHOL
PATIENT CONSUMES 90ML OF WHISKEY 4 TIMES A DAY SINCE 6 MONTHS DUE TO PERSONAL PROBLEMS.
FAMILY HISTORY - NO SIGNIFICANT FAMILY HISTORY REPORTED.
GENERAL EXAMINATION -
THE PATIENT WAS CONSCIOUS, COHERENT AND CO-OPERATIVE.
NO PALLOR, NO ICTERUS, NO CYANOSIS, NO CLUBBING , NO LYMPHADENOPATHY. B/L PEDAL EDEMA PRESENT.
PULSE RATE- 75BPM
RESPIRATORY RATE - 16 CPM
TEMPERATURE - AFEBRILE
BP - 130/80 MM HG
SPO2 98%
GRBS 174 MG%
SYSTEMIC EXAMINATION -
CVS - S1, S2 HEARD, NO THRILLS, NO MURMURS
RESPIRATORY SYSTEM - NO DYSPNEA, NO WHEEZE, NVBS HEARD, POSITION OF TRACHEA CENTRAL
ABDOMEN - NO TENDERNESS, NO PALPABLE MASS, NO FREE FLUID, LIVER AND SPLEEN NOT PALPABLE
CNS - PATIENT IS CONSCIOUS, SPEECH - NORMAL
NFND
Treatment Given
1) INJ. THIAMINE 1 AMP IN 100 ML NS IV/TID
2) INJ. PAN 40 MG IV/OD
3) INJ. ZOFER 4MG IV/ TID
4) TAB. UDILIV 300MG BD
5) TAB. LASILACTONE 20/50 MG BD
6) TAB. PENTOXIFYLLINE 400MG TID
7) TAB. PREDNISOLONE 40 MG/OD
8) TAB PREGABACIN 75MG BD
9) BP/PR/TEMP/SPO2 MONITORING
Advice at discharge
1) TAB BENFOMET PLUS
2) TAB. PREDNISOLONE 40 MG/OD
3) TAB PAN 40 MG OD
4) TAB. UDILIV 300MG BD
5) TAB.VIBOLIV 500 MG TID
6)TAB. PENTOXIFYLLINE 400MG TID
7) TAB PREGABALIN 75MG BD
Follow up:
Review after 1 week to medicine OPD
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