27 YEAR OLD MALE WITH HEPATIC ENCEPHALOPATHY

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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 and to comprehend clinical data including history, clinical finding investigations and come up with a diagnosis and treatment plan.

CHIEF COMPLAINTS 

- Loss of appetite since 20 days

- Malena since 20 days 

- Tremors since 15 days 

- Blood in urine since 10 days 

- Pedal edema since 10 days 

HISTORY OF PRESENTING ILLNESS

Patient was apparently alright 20 days back then he developed loss of appetite for which he went to the hospital and was diagnosed as a CLS case with spleenomegaly with portal hypertension and took medication. He also developed Malena since 20 days which laster for 10 days. He also complained of tremors since 15 days. After that he complained of hematuria since 10 days and pedal edema which was pitting type, relived on taking rest and aggravated on walking. 

No h/o abdominal pain, vomitings, burning micturation, loose stools. 

PAST HISTORY

Not a known case of Hypertension. Diabetes, tuberculosis, CVD, thyroid disorders, epilepsy

H/O appendectomy

FAMILY HISTORY 

No relavent family history

PERSONAL HISTORY 

Diet: mixed

Appetite: Normal 

Bowel and bladder: Normal 

Sleep: Adequate 

Addictions: alcohol consumption (Whisky 500 ml daily)

Daily routine

4 am: wake up 

8 am - 8:30 am: breakfast 

1 pm - 3 pm: lunch 

7:30 - 8:30: drinks alcohol 

9 pm: dinner 

GENERAL EXAMINATION 

Patient is consious, coherent and cooperative.

Well oriented to time place and person

Moderately built and moderately nourished.

No Pallor, Icterus, Cyanosis, Clubbing, lymphadenopathy, Edema

On Examination: 

Temp: 97.6 degrees

PR- 95 bpm

BP: 100/60 mmHg

Sp02: 95% at room air 

GRBS: 75 mg%

SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM: 

UPPER RESPIRATORY TRACT:

No halitosis, post nasal drip, tonsils, dental caries, dns, polyps, sinus tenderness

Oral hygiene present

LOWER RESPIRATORY TRACT: 

INSPECTION: 

Chest is symmetrical in shape

Trachea is in the midline (trails sign)

Apical impulse not visualised 

No drooping of shoulder, supraclavicular and infraclavicular hollowing, indrawings, retractions, crowding of ribs 

No pectus carinatum, pectus excavatum, kyphoscoliosis, winging of scapula

No sinuses, scars, dilated veins, nodules 

Normal movements with respiration

PALPATION: 

No local rise of temperature 

All inspectory findings confirmed 

Expansion of the chest is symmetrical 

Tactile vocal fremitus: normal 

PERCUSSION: 

Resonant note 

AUSCULTATION: 

Normal everywhere except the left inframammary area where crepts can be heard.  

CVS: 

S1, S2 heard

PER ABDOMEN: 

Soft non tender 

CNS: 

No focal neurological deficits 

PROVISIONAL DIAGNOSIS: 

Decompensated liver disease - grade 1 (Hepatic encephalopathy)

Hypotonic hyponatremia - diuretic induced 

CLINICAL FINDINGS:

INVESTIGATIONS:

SERUM CREATININE: 0.5 mg/dl 

SERUM ELECTROLYTES: 

- Sodium: 128 mEq/L

- Potassium: 3.6 mEq/L

- Chloride: 105 mEq/L

- Calcium ionized: 0.99 mmol/L

RBS: 75 mg/dl 

Prothrombin time: 18 Sec

INR: 1.3 

APTT TEST: 35 Sec

SERUM MAGNESIUM: 2.0 mg/dl

SERUM AMYLASE: 191.2 IU/L

TREATMENT:

1. IV Fluids NS @ 75 

2. INJ VIT K 10 mg IV/STAT

3. INJ THIAMINE 200 mg IV/BD in 100 ml NS 

4. Syp. LACTULOSE 10 ml PO/BD 

5. Strict I/O charting 

6. Vitals monitoring - 2nd hourly