32 YEAR OLD WITH CLD SECONDARY TO ALOCHOL

November 15, 2021

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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 plan.

A 32 year old male presented to the opd with CHEIF COMPLAINTS of yellowish discoluration of eyes and passage of dark yellow coloured urine since 1 month.

[ ] HISTORY OF PRESENT ILLNESS......

Patient was apparently asymptomatic one month ago then he went to village for some occassion and had developed fever and was tested dengue positive and was also diagnosed to be ?liver failure ( Total bilirubin- 5gm/dl) . 3 days later after getting back from the village he was taken to miryalaguda and that his total bilirubin was 10 gm/dl for which he was given some medication and alcohol abstinance, but the patient continued drinking . He also used herbal medication for 1 week as he developed itching all over the body he stopped taking the herbal medication.

He is married for 10 years, childless didn't get tested , significant alcohol history . Starting with white liquor around the age of 15-16 years it increased to cheap liquor / whisky ,daily intake of around 180 - 360 ml . H/o alcohol abstinance 2 years back for 1 year and resumed drinking last year .
H/o smoking for 4-5 years . He stopped smoking since the last 4 years .
NO history of nausea and vomiting , pedal edema , abdominal distension .
[ ] PAST HISYORY....
Not a known case of DM , HTN, ASTHMA , EPILEPSY , TB , CAD.

[ ] PERSONAL HISTORY......
Occupation - welding work in reddys laboratory.
Diet - Mixed diet
Appetite - Normal
Bowel and bladder - Regular
Sleep - adequate
Addictions -
Consumes alcohol regularly around 180- 360 ml.
H/o smoking for 4-5 years around 10-15 beedis / day. He stopped smoking since the last 4 years .
H/o chewing chaini khaini ocassionally.
[ ] FAMILY HISTORY...
No significant family history.

[ ] GENERAL EXAMINATION....

Patient is conscious , coherant , cooperative .
Well oriented to time place and person
ICTERUS - PRESENT
No pallor, cyanosis , clubbing , lymphadenopathy, edema .

VITALS :
TEMP - 98.6 F
BP - 100/70 MMHG
PR - 82/ MIN
RR - 16 /MIN
SPO2 - 98 % ON RA.

SYSTEMIC EXAMINATION
CVS - S1, S2 +
RS - BAE + , NVBS
P/A -
- SHAPE OF ABDOMEN - OBESE
- ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION
- NO SCARS AND SINUSES
- HERNIAL ORIFICES ARE FREE.
- SPLEENOMEGALY IS PRESENT
- NO HEPATOMEGALY
- BOWEL SOUNDS +

CNS
HIGHER MOTOR FUNCTIONS- INTACT
CRANIAL NERVES EXAMINATION - NORMAL
SENSORY SYSTEM- INTACT
MOTOR SYSTEM EXAMINATON - NORMAL
REFLEXES -
B T S K A P
R 2+ 1+ 1+ 2+ - WITHDRAWL

L 2+ 1+ 1+ 2+ - WITHDRAWL

CEREBELLAR EXAMINATION :
FINGER NOSE COORDINATION - PRESENT
KNEE HEEL COORDINATION - PRESENT

PROVISIONAL DIAGNOSIS
Chronic liver disease secondary to ? Alcohol .

INVESTIGATIgiven:

13/11/21

CBP

HB- 10.2

TLC - 7800

PLT - 1.57

LYMPHOCYTES - 12

LFT

TB- 15.9

DB - 7.10

AST - 366

ALT - 71

ALP - 358

TP- 7.2

ALB- 3.0

A/G - 0.71

CUE

COLOR - BROWNISH

APPERANCE - CLEAR

ALBUMIN - TRACE

SUGARS - NIL

BILE SALTS - NIL

BILE PIGMENTS - NIL

PUS CELLS - 2-4

EPITHELIAL CELLS - 1-3

RBC - NIL

BLOOD UREA - 12

CHEST X RAY: