Case of a 59 year old man .

 This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians signed informed consent. This Elog reflects my patient centered online learning portfolio.

This Elog was created under the guidance of Dr Naveen (Intern).

This is the case of a 59 year old male. He is a carpenter by occupation.

He came to casualty with altered state of consciousness.

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 3 months ago , then he had fever - low grade , intermittent , relieves with medication , and not associated with chills and rigor , for 5 days .

He had abdominal distension for 15 days , ascitic tap was done and was told that he had a liver problem, in another hospital.

On 2/7/2021- He had sudden onset of drowsy state and would not respond to their commands.

On 10/7/2021- He became normal and was discharged.

Patient was asymptomatic and was following his normal routine like eating, brushing, bathing for 7 days .

On 17/7/2021- He again became drowsy. He was not able to eat food and brush .

He was admitted in a private hospital for 2 days . As his condition was not improving , his family brought him home and fed him through Ryles tube. As his condition deteriorated day by day ,he was brought to our hospital in a drowsy state.

HISTORY OF PAST ILLNESS

History of altered sensorium one month ago. He was diagnosed with chronic liver disease and portal hypertension one month back.

DRUG HISTORY 

No significant drug history.

PERSONAL HISTORY 

Bowel and bladder movements - Regular

Appetite - Normal

Chronic alcoholic since 20 years 

Non smoker.

Patient is not a known case of hypertension , DM, asthma, epilepsy and tuberculosis.

FAMILY HISTORY

No significant family history .

GENERAL EXAMINATION

Patient is unconscious , non cooperative , disoriented

No pallor, icterus, cyanosis, clubbing , and edema.

No generalised lymphadenopathy.

Brudzinski's sign - Positive 

VITALS AT ADMISSION 

E2 V2 M5

Temperature -96.5 degrees fahrenheit

Pulse- 93 bpm

BP- 110/80 mmHg

Respiratory rate- 24 cpm

SpO2- 98%

SYSTEMIC EXAMINATION

CVS - 

S1 S2 heard

no thrills and murmurs

RESPIRATORY-

BAE+

NVBS

CNS-

                        Rt              Lt

Tone -    UL   Hypo.        Hypo.

               LL   Hypo.        Hypo.

Power-   UL     --              --

               LL     --              --

Reflexes- B      +              --

                T      --              --

                S      --              --

                K     --               --

                A      --              --

                P       --              --

  

PER ABDOMEN 

Distended, non tender.

No palpable mass

INVESTIGATIONS 

DAY 1 

APTT - 32 seconds 

BGT - O +ve 

PT - 16 seconds 

INR - 1.11 

HEMOGRAM - 

HB- 9.9 g/dl 

TLC- 8500 cells per cubic millimeter

Neutrophills - 74 percent 

Leukocytes - 10 percent 

Monocytes - 10 percent 

Eosinophills - 6 percent 

PCV - 28.1 percent 

MCV - 79.6 percent 

MCH- 28 percent 

MCHC- 35.2 percent 

RDW SD- 48 percent 

RDW-CV- 16.7 percent 

RBC - 3.53 millions 

Platetlets - 1.79 lacks per millimeter cube 

Smear - Normocytic , normochromic 

LFT - 

Total billirubin -1.82 mg/dl

Direct Billirubin -0.48 mg/dl 

SGOT -20 IU/L

SGPT - 10 IU/L

Total Protein - 6.1 g/dl

Albumin - 2.2 g/dl

A/G- 0.57 

SERUM ELECTROLYTES

Sodium - 128 mEq/L 

Potassium - 3.8 mEq/L

Chlorine - 92 mEq/L

RANDOM BLOOD SUGAR - 73 mg /dl 

SERUM UREA - 1.2 mg/dl

BLOOD UREA - 61 mg/dl

ECG

ECHO

PROVISIONAL DIAGNOSIS-

Altered sensorium under evaluation.

Hepatic encephalopathy?

DIAGNOSIS

HEPATIC ENCEPHALOPATHY

CHRONIC LIVER DISEASE

GRADE I - BED SORE

TREATMENT

1.DATE- 5.8.2021

 RT feeds - 

-100 ml free water 1 hourly 

-200 ml milk 4th hourly 

2. IVF @ 75 ml per hour 

-NS

-RL

-DNS

3. Syrup - HEPAMERZ 10ml RT BD 

4. Syrup - LACTULOSE 10ml RT TID 

5. Tab - RIFAGUT 550 mg RT BD

2. DATE-6.8.2021

1.RT Feeds

-100 ml free water 1 hourly

-200 ml milk 4th hourly

2. IVF Ions @ 50ml per hour

3. Syrup - LACTULOSE 10ml RT TID

4. TAB NORFLOXACIN 400mg

5. Frequent change in position every 2nd hour

6. Syrup- HEPAMERZ 

7. OINT. THROMBOPHOR for L/A 

3.DATE- 7.8.2021

1.RT Feeds

- 100 ml water- 1 hourly

- 200 ml milk- 4th hourly

2.IVF Ions @ 50 ml/hour

3.Syrup- LACTULOSE 10ml RT TID

4.Tab RIFAGUT 550 mg RT BD

4. DATE- 8.8.2021

1. RT Feeds 

-100 ml water - 1 hourly

-200 ml milk- 4th hourly

2. IVF Ions @ 50 ml/hour

3.Syrup LACTULOSE 10 ml RT TID

4.TAB. RIFAGUT 550mg RT BD

5.Soap water enema 

5.DATE - 9.8.2021

1.RT Feeds 

-100 ml water - 1 hourly

- 200 ml milk - 4th hourly

2.IVF Ions @ 50 ml/hour

3.Syrup LACTULOSE 20 ml RT TID

4.TAB RIFAGUT 550 mg RT BD

5.Soap water enema BD (8 am-x-5 pm)

6. Maintain stools (2-3 )/day

7. GRBS 6th hourly (8 AM--2PM--8PM--2AM)

PATIENT SUMMARY

59 year old male carpenter who had a routine of work from 9 AM to 6 PM and indulgence in alcohol in the evening .Patient honed the skill of carpentry at the age of 18  Since then he would work to fulfill his necessities . He had an intriguing history of abstinence for 1 year, after which never ending tremors pulled him back to binge on alcohol.

Patient used to work hands on until 2018 , when he met with an RTA which fractured his left leg .After this he limited himself to supervising at his warehouse.