A 27 year old male with generalised weakness since 20 days and yellowish discoloration of eyes since 2 years

16 APRIL 2023

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

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

CHIEF COMPLAINTS:

Yellowish discolouration of eyes since 2 years  

Swelling of feet since 20 days 

Generalised weakness since 20 days 

Loss of appetite since 20 days 

Fever since 2 days 

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 2years back,then his mother noticed that her son was frequently complaining of generalised weakness and not eating anything and then a week after she noticed yellowish discoloration of eyes,for which she took him to hospital where they treated him in view of his addiction to alcohol and suggested him to abstain from alcohol.He took medication and stopped drinking for about a week and started consuming alcohol again.Then 8 months later he started having the similar complaints and was taken to hospital and doctor advised him to stop drinking alcohol but he did not listen and continued the habit.

Now since 20 days the patient started having generalised weakness which was insidious in onset and gradually progressive, associated with loss of appetite and swelling of feet confined upto ankles,it increased on walking and decreases on lying down chest pain, palpitations,facial puffiness,decreased urine output.

Yellowish discoloration of eyes since 2 years which was insidious in onset,gradually progressive associated with high coloured urine since 2 years and since 20 days patient complaints of darkly stained stools,only one such episode is reported in the past 2 years not associated with constipation,diarrhoea.

Blood in urine since 10 days and not associated with decreased urine output ,increased frequency, urgency, burning micturation.

Patient is having low grade fever since 2days which is insidious in onset, gradually progressive,intermittent, decreased on medication and not associated with chills,rigor,night sweats, evening rise of temperature,myalgia,joint pain,rashes.

H/o of tremors ,palpitations,fearfulness ,sweating if he stopped alcohol since 1 year 

H/o hair loss since 2 years .

No complaints of  difficulty in breathing, orthopnea ,PND, hemetesis ,foul smelling breath, frequent bruises ,abdominal distensiom and abdominal pain ,nausea ,vomiting ,loose stools, confusion,altered sensorium ,lack of interest in work,decreased self care hygiene.

PAST HISTORY:

Two episodes of jaundice  in the past two years for which he was taken to the hospital and declared a case of chronic liver failure .

N/k/O HTN ,DM ,TB,asthma ,heart disease,seiizures 

No history of blood transfusions,tattooing or IV drug abuse ,recent travel 

TREATMENT HISTORY:

Deaddiction medication for a week 2 years back .

Diuretics in view of pedal edema 

SURGICAL HISTORY:

Patient underwent appendectomy 4 years ago .

FAMILY HISTORY:

No similar complaints in the family 

PERSONAL HISTORY:

27 year old male unmarried ,resident of miryalguda ,a labourer by occupation

Finished education till 10 standard,started consuming alcohol since the age of 21,initially consumed toddy later Whiskey since last 3 years, usual consumption -1/2 bottle of whiskey everyday (180ml)

not a known smoker 

Not going to work since past 15 days 

DIET -mixed 

APPETITE -decreased since 2 years 

BOWEL BLADDER - regular 

SLEEP - increased sleepiness during day time since last 20 days 

ADDICTIONS - alcoholic since 6 years 

GENERAL EXAMINATION:

Patient is conscious,coherent and co operative well oriented to time, place and person 

Patient is moderately nourished and moderately built 

Height -5’7

Weight -48kgs 

Pallor -absent 

Icterus -present in upper bulbar conjunctiva 


Cyanosis -absent 

Clubbing -present (grade-2 increase in normal angle 160 * between nail bed and proximal nail fold )


lymphadenopathy -absent 

Pedal edema - pitting type Upto ankles

Hair is sparse 

No parotid swelling 

Palmar erythema- absent 

Gynaecomastia -absent 

Pale coloured nails -present 

Tremors are present 

Absent spider naevi 

Petechae-absent 

abdominal scar -midline extending from umbilicus to 1cm above pubic symphysis 

Vitals:

Temperature-100.5 F

Blood pressure-110/80mm Hg

Pulse-74bpm

RR-17cpm,abdominothoracic

SYSTEMIC EXAMINATION:

ABDOMINAL EXAMINATION:


INSPECTION-

Abdomen is scaphoid in shape , no flank fullness 

Umbilicus has scar contracture

Skin is normal with midline scar from umbilicus to 1cms above pubic symphysis below 

No discolouration of skin ,engorged veins,sinuses 

No visible peristalsis or pulsations 

Hernial orifices Normal 

PALPATION-

Abdomen is non tender , with rise of temperature due to fever 

No guarding and rigidity 

No organomegaly 

PERCUSSION-

liver :Upper border of liver dullness is percussed at the right 6th ics along the mid -clavicular line on full expiration and the lower border at 5 cms below the rt costal margin 

Liver span-12 cms 

Spleen:

Castell’s method - dullness is observed in 9 th ICS of anterior axillary line 

No fluid thrill  

shifting dullness present

AUSCULTATION-

Bowel sounds heard

CNS EXAMINATION:

Conscious,coherent and cooperative 
Speech- normal
No signs of meningeal irritation. 
Cranial nerves- intact
Sensory system- normal 

Motor system:
Tone- normal
Power- bilaterally 5/5
Reflexes: Right. Left. 
Biceps. ++. ++

Triceps. ++. ++

Supinator ++. ++

Knee. ++. ++

Ankle ++. ++

CARDIOVASCULAR SYSTEM EXAMINATION:

Inspection : 
Shape of chest- elliptical 
No engorged veins, scars, visible pulsations
JVP - not raised
Palpation :
 Apex beat can be palpable in 5th inter costal space
No thrills and parasternal heaves can be felt
Auscultation : 
S1,S2 are heard
no murmurs.

RESPIRATORY SYSTEM EXAMINATION:

Inspection: 
Shape- elliptical 
B/L symmetrical , 
Both sides moving equally with respiration .
No scars, sinuses, engorged veins, pulsations 

Palpation:
Trachea - central
Expansion of chest is symmetrical. 
Vocal fremitus - normal
Percussion: resonant bilaterally 

Auscultation:
bilateral air entry present. Normal vesicular breath sounds heard.

PROVISIONAL DIAGNOSIS:
Acute episode due to underlying chronic liver disease.


INVESTIGATIONS:
ULTRASOUND:
fatty liver grade -1 with hepatosplenomegaly 

FINAL DIAGNOSIS:
Decompensated liver disease


Comments

Popular posts from this blog

A 66 YEAR OLD MALE WITH MULTIPLE PAINFUL BLISTERS

MY EXPERIENCES WITH GENERAL CELLULAR AND NEURAL CELLULAR PATHOLOGY IN A CASE BASED BLENDED LEARNING ECOSYSTEM'S CBBLE