32 year old male with complaints of yellowish discolouration of eye since 45 days.

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32 year old gentleman who is a GHMC worker came to the hospital with chief complaints of 

•yellowish discolouration of eyes since 45 days

•SOB since 10 days 

• cough since 5 days

• fever since 3 days.

History of presenting illness:- 

Patient was apparently asymptomatic 6 months back , then he developed yellowish discolouration of eyes .

• For this problem he used local medicine ( natuvedyam) and stopped consuming alcohol for about 3 months.

• Due to stopping of alcohol consumption his bilirubin levels came down , following which he again resumed consuming alcohol.

• After drinking alcohol ,he fought with his friend and injured his right arm causing fracture which was left untreated.( used natuvedyam).

• Recurrence of yellowish discolouration of eyes occurred after 1 month,again he started using natuvedyam .

•He also had an episode of GTCS 1 month ago after stopping alcohol for about 10 days.( alcohol withdrawal).

• Again yellowish discolouration occurred 1 month ago, then he stopped alcohol again.

•But this time , discolouration got progressed and his entire body turned yellow.

• C/o pedal edema, abdominal distension since 4 days.

•c/ o productive cough since 5 days.

•C/o SOB since 5 days which was grade 4.

•c/o fever since 3 days-low grade.

Past history:-

No history of DM, HTN, TB  epilepsy, CAD.

Personal history :- 

Diet- mixed

Appetite- normal

Sleep - adequate

Bowel and bladder movement- regular

Regularly consumes alcohol 90-180 ml of alcohol since 18 years.

General examination:-

he is conscious, coherent , cooperative, moderately built and moderately nourished.

Pallor - present.

Icterus -present.

Cyanosis- absent

Clubbing-absent.

Lymphadenopathy-absent.

Pedal edema -present.

Vitals:-

Temperature- 99°F

PR- 110bpm

Bp- 140/90 mmhg

RR- 20CPM

SPO2- 100%@ RA

GRBS -176 mg/dl.

Systemic examination:-

P/A:- soft, non tender, liver and spleen were palpable.

Bowel sounds -heard

Tremors - present.

CVS:- s1,s2 heard. No murmurs.

RS- BAE, NVBS heard.

CNS-no focal neurological deficit.

Provisional diagnosis:-

Acute or chronic liver disease 

Hepatic encephalopathy-Grade 1 Hypokalemia.

Investigations:-

Day 1 of admission:

Day 2 of admission:

Day 3 of admission:

Treatment:-

Inj.lasix 40mg iv/BD

Tab.aldactone 25mg PO/ BD

Temperature charting 4 holy

Tepid sponging SOS 

Inj. Vit k 10 mg slow IV / OD

Syp. Ascoryl ls 10 ml PO/BD

Syp. Potchlor 10 ml in 1 glass of water PO/BD.

Syp.lactulose 10 ml P/O H/s