Gen Med E-log August - 1

E-LOG GENERAL MEDICINE
Hi, This is Rithika, a fifth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from  patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them

A 25 YR OLD WITH ALCOHOLIC LIVER DISEASE

Chief complaints:

A 25 yr old male hailing from Yadagirigutta, slab welder by occupation, came with the chief complaints of :

• Fever, since 8 days
• Stomach tightness and bloating since 8 days ( especially after meals) 
• Nausea and vomitings since 8 days
• SOB since 8 days
• Anxiety
• Thigh pains


HOPI:

• Apparently pt. was asymptomatic 6 mnths back. 

• He developed fever, cold and cough which persisted for a week, for which he took medication in a local hospital for Jaundice. 

• Medications worked and his symptoms got relieved, immediately after which he started taking alcohol. 

• Again a month later he developed fever, stomach bloating for which he took some plant medicine and got relief after using them for a month. Then, he stopped using them. Again he started taking alcohol!! 

• After around 4-5 days, he developed fever, stomach bloating for which he for which he got admitted at our hospital. 

• He also has a h/o night sweats and night fevers, SOB at rest, mild cough since 8 days. 

Patient's day to day routine before illness:

• He used to get up around 6am and go to work by 7am.
• Had his first meal around 9am and continue with his work followed by lunch at 2pm.
• He used to finish his work by 7pm and then go to drink alcohol accompanied by his friends ( qty : half  a bottle) and then head back home have dinner and sleep. 
• Also throughout the day, he smokes cigarettes 1pack/day.

Patient's daily routine after the illness:

• His schedule is no longer the same. 
• He is frequently very ill due to which couldn't work normally anymore. 
• Also even after a smallest meal, he feels very bloated and is afraid to eat. 
• Has frequent fevers and also developed anxiety. 
• Doesn't have social life like before and vexed up by the medication he is taking in a very young age. 

Past history : Nil significant

Family history :  Nil significant

Personal history:

• Has a history of smoking and alcohol consumption since 10 yrs
• Sleep - inadequate
• Appetite - normal, but is afraid to eat due to excessive bloating
• Diet - Vegetarian since 5 yrs
• Bowel and bladder habits normal
• No allergies

GENERAL EXAMINATION:

Vitals:

• BP:
• Temp. :
• PR : 98bpm
• RR : 22cycles/min
• SpO2 : 98

GE:

• Pallor - present
• Icterus - present
• Cyanosis - absent
• Clubbing - absent
• Oedema - absent
• Lymphadenopathy - absent






SYSTEMIC EXAMINATION :

CVS:
• Thrills and murmurs absent

RS :
• Dyspnoea present

P/A :
• Abdomen distended


CNS :  Normal

PROVISIONAL DIAGNOSIS :

DECOMPENSATED LIVER DISEASE WITH RT. SIDED MILD PLEURAL EFFUSION WITH GRADE 1 HEPATIC ENCEPHALOPATHY

INVESTIGATIONS :


TREATMENT :


🎀🎀🎀🎀🎀🎀

UPDATE OF THE CASE :

Unfortunately, had to see the pt again with the same complaints of the past but with more severity. 

Chief complaints:

• Severe bloating of stomach since 1 week
• Loss of appetite since 1 week
• Vomitings since 1 week, present even without taking food
• SOB since 5 days ( unable to get up and walk even for a shorter distance) 
• Cough since 5 days

HOPI :

• After getting admitted in the hospital for nearly 13 days from the last visit, he was managed symptomatically, counselled well about his addictions and got discharged. 
• The first 2 days at home, he took his medications regularly and even abstained from alcohol. 
• But again from the next day, started taking alcohol day and night 90ml.
• Since then he again developed SOB, stomach bloating, vomitings, cough which persisted for 5 days. 
• So, he decided to come back to the hospital to get treated. 

General Examination :

Pallor - present
• Icterus - present
• Cyanosis - absent
• Clubbing - absent
• Oedema - absent
• Lymphadenopathy - absent

Vitals :
• BP:
• Temp. :
• PR : 98bpm
• RR : 22cycles/min
• SpO2 : 98 %

Systemic Examination :

CVS :

S1, S2 heard
No thrills and murmurs present

RS:

Trachea central
Breath sounds vesicular
No adventitious sounds
Dyspnoea present

P/A:

Abdomen distended
Fluid thrill present


Provisional diagnosis :

Hepatopulmonary syndrome

Investigations :


Treatment :

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