Geetha 54.

 11 march 2022

Chief complaint

40 years old male who is a fruit vendor was brought to the OPD generalised weakness and fever since 2 days back excessive sleepiness since 2 days

Past history

He was apparently asymptomatic till 5 years

Since 5 years patient started drinking after he had financial problems

He was brought to the hospital in the view of Re-addicted centre previously and was admitted for 40 days and was discharged

After started drinking again after few days intermittently

He was alcoholic since 6 years and he last drunk 4days ago before he get admitted in the hospital

Vitals 

Bp-120/70 mm hg

PR -125bpm

GRDS-154mg/dl

SpO2 -97% on RA

Temp-100. 8°F

Investigations










Liver -16. 5cm increased in size
Spleen - 13.2 cm increased in size

1) Grade III Fatty liver with mild hepatomegaly with mild caudate lobe hypertrophy
Early liver parenchymal disease
2) mild Splenomegaly

Provisional diagnosis

DECOMPENSATED   LIVER DISEASE

ALCOHOL DEPENDENCE SYNDROME

Patient was drowsy and Arousable

Decreased appetite

Yellowish discoloration of eyes

CVS- S1 and S2 positive

RS-BAE positive; NVBS

P/A soft and distended-variable abdominal veins

CNS-NAD

Cirrhosis of liver (portal hypertension)

Hepatomegaly

Jaundice

Spider naevi on the chest

Treatment

1) T. OXAZEPAM 15mg

2) T. LEVITIRACETAM 500mg BD

3) NICOTEX ROMS 2mg

4) T. BEN XL

5) T. ALDARTONE 25 mg

6) T. UDILIV 800 mg

7) T. RIFARIMINE 550mg

8) Syp. LARTULOSE

9) Inj. ZOFER 4 mg IV

10) Inj. THIAMINE 1amp in 100 ml 

11) Inj. RAN 40mg IV TID




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