35 yrs old M with yellow discoloration since 1week

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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 .

This is a case of 35yr old presented to casuality with the complaints of yellowish discolouration of eyes since 1 week,

Dark coloured urine since 1 week.

HOPI:

                He was apparently asymptomatic 1 week back then he developed yellowish discolouration of eyes since 1 week which was insidious in onset,gradually progressive

Dark coloured urine since 1 week which is on and off .patient complaints of pale coloured stools since 1 week,not blood stained.

                   Patient complaints of swelling of both lower limbs,since 1 week extending upto the ankle,pitting type,aggrevated on walking and relieved by rest. 

        No complaints of pain abdomen,abdominal distension/bloating.

 No complaints of nausea,vomiting,chestpain,shortness of breath.

Past History:

         Not a known case of Dibetes,Hypertension,Tuberculosis,Asthma,Cva ,Cad,Thyroid disorders.

Family History:

      Not relevant .

Personal History:

      Diet: mixed

    Appettite:normal

  Bowel and bladder: Regular

      Sleep: Adequate

   -He is regular alcoholic since 10 yrs drinks 150ml per day

  -Doesnot smoke

 

GENERAL EXAMINATION 

Patient was conscious,coherent  cooperative

Moderately build and moderately nourished

well oriented to time ,place and person

Pallor : no pallor

Icterus: present 

 chest x ray

ECG

ABG

Provisional diagnosis:

        Alcoholic Hepatitis

   

Treatment:

INJ.TREMADOL 1amp  100mlNS IV /SOS

INJ .UDILIV 300mg PO/BD

TAB.RIFACXMIN  550MG PO/BD 

TAB.MUCINOC  PO/BD

INJ.KCL 2AMP IN 500ML NS IV OVER 6 HRS

SYP.HEPAMERZ  15ml/PO/BD

SYP LACTULOSE PO/OD

TAB.PANTOP 40MG PO/OD

 

TAB.ULTRACET  1/2 tab. PO/BD

BP MONOTORING HOURLY

INJ.THIAMINE  1 amp in 100ml NS/IV/BD