A case of HEPATIC ENCEPHALOPATHY.

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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 and to comprehend clinical data including history, clinical finding investigations and come up with a diagnosis and treatment plan.

CHIEF COMPLAINTS 

- Loss of appetite since 20 days

- Malena since 20 days 

- Blood in urine since 20 days 

- Pedal edema since 7 days 

Tremors since 2 yrs .

HISTORY OF PRESENTING ILLNESS

Patient was apparently alright 20 days back then he developed loss of appetite and generalized weakness following a heavy bout of  alcohol for which he went to the hospital and was diagnosed with liver dysfunction.

 He also developed Malena since 20 days . With no history of constipation,loose stools,vomiting,pain abdomen.

He also noticed hematuria since 20 days not associated with burning micturition or pain during micturition.

Patient complaints of reduced sleep during night time and progressively increasing drowsiness since 20 days.

After that he complained of pedal edema which was  relived on taking rest and aggravated on walking since 7 days.

History of intermittent fever without any diurnal variations associated with chills since 2 days which was in control with medication.

Abdominal distension since 2 days.

History of alopecia since 2 yrs.

Yellow colored eyes since 2 yrs.

He also complained of tremors since 2 yrs associated with abstinence from alcohol.

No history of seizures,pain or stiffness in the joints.

PAST HISTORY

Not a known case of Hypertension. Diabetes, tuberculosis, CVD, thyroid disorders, epilepsy

H/O appendectomy 4 yrs back.

FAMILY HISTORY 

No relavent family history

PERSONAL HISTORY 

Diet: mixed

Appetite:loss of appetite since 20 days

Bowel and bladder: Hematuria and malena

Sleep: Inadequate 

Addictions: alcohol consumption (Whisky 500 ml daily)

Chronic alcoholic since 8 yrs.

Daily routine

4 am: wake up 

8 am - 8:30 am: breakfast 

1 pm - 3 pm: lunch 

7:30 - 8:30: drinks alcohol 

9 pm: dinner 

GENERAL EXAMINATION 

Patient is mildly confused

Well oriented to time place and person

Moderately built and moderately nourished.

No Pallor,

 Icterus is present ( mustard yellow discoloration of bulbar conjunctiva), 

Cyanosis absent

Clubbing present (drumstick appearance)

No lymphadenopathy

Bilateral pedal edema is present grade 1 pitting type.

On Examination: 

Temp: 97.6 degrees

PR- 95 bpm

BP: 100/60 mmHg

Sp02: 95% at room air 

GRBS: 75 mg%

SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM: 

UPPER RESPIRATORY TRACT:

No halitosis, post nasal drip, tonsils, dental caries, dns, polyps, sinus tenderness

Oral hygiene present

LOWER RESPIRATORY TRACT: 

INSPECTION: 

Chest is symmetrical in shape

Trachea is in the midline (trails sign)

Apical impulse not visualised 

No drooping of shoulder, supraclavicular and infraclavicular hollowing, indrawings, retractions, crowding of ribs 

No pectus carinatum, pectus excavatum, kyphoscoliosis, winging of scapula

No sinuses, scars, dilated veins, nodules 

Normal movements with respiration

PALPATION: 

No local rise of temperature 

All inspectory findings confirmed 

Expansion of the chest is symmetrical 

Tactile vocal fremitus: normal 

PERCUSSION: 

Resonant note 

AUSCULTATION: 

Normal everywhere except the left inframammary area where crepts can be heard.  

CVS: 

S1, S2 heard

No murmurs 

ABDOMINAL EXAMINATION:

SIGNS OF LIVER FAILURE:

alopecia present

Facial puffiness is present

Astrexis present 

Jaundice present.

INSPECTION:

Shape is distended

Umbilicus inverted

Appendectomy scar is present

PALPATION:

local rise of temperature present 

No tenderness 

Lower border of live is palpable 9 cm below the xiphisternum 

Spleen is not palpable .

PERCUSSION:

Liver spam 16 cm

No shifting dullness and fluid thrill

ASCULTATION:

5 bowel sounds per minute.

CENTRAL NERVOUS SYSTEM:

Mild confusion,coherent and cooperative 

Slurred speech

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- reduced.

Power- bilaterally 5/5

Reflexes: Right. Left. 

Biceps. ++. ++

Triceps. ++. ++

Supinator ++. ++

Knee ++,++

Ankle ++,++

PROVISIONAL DIAGNOSIS: 

grade 1 (Hepatic encephalopathy) secondary to alcoholic liver disease with hepatomegaly.

CLINICAL FINDINGS:

INVESTIGATIONS:

SERUM CREATININE: 0.5 mg/dl 

SERUM ELECTROLYTES: 

- Sodium: 128 mEq/L

- Potassium: 3.6 mEq/L

- Chloride: 105 mEq/L

- Calcium ionized: 0.99 mmol/L

RBS: 75 mg/dl 

Prothrombin time: 18 Sec

INR: 1.3 

APTT TEST: 35 Sec

SERUM MAGNESIUM: 2.0 mg/dl

SERUM AMYLASE: 191.2 IU/L

TREATMENT:

1. IV Fluids NS @ 75 

2. INJ VIT K 10 mg IV/STAT

3. INJ THIAMINE 200 mg IV/BD in 100 ml NS 

4. Syp. LACTULOSE 10 ml PO/BD 

5. Strict I/O charting 

6. Vitals monitoring - 2nd hourly .