30year old male with alcoholic fatty liver

 VARSHHA ALVALA

ROLL NO:169

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box A 30year old male with alcoholic liver cirrhosis 

A 30yr old male with alcoholic fatty liver 

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome."

30 year old man,labour by occupation,came with the chief complaints of: 

 • Head injury associated with loss of consciousness and

• Tremors 2days ago.

 

History of present illness- 

The patient was apparently asymptomatic one week ago,then he experienced loss of consciousness 

which was due to alcohol consumption and then he fall himself on ground.Following which there were appearance of bruises.There were even formation of scabs over his body which were caused when he hit himself on hard surfaces at the time of unconscious.

history of 

 -vomiting 2 days ago

-fever,headache,sore throat, since 2 days

-severe body aches from past one week

-productive cough since 2days

-loss of appetite 

-orthopnea

Past history : 

No h/o DM, HTN, TB, BA, Epilepsy and thyroid abnormalities.

Family h/o: 

No similar complaints in family 

No h/o DM, HTN, TB, BA, Epilepsy, CVA, CAD.

Personal h/o: 

       Diet- mixed    

       Appetite-reduced

       Sleep- not adequate 

       Bowel and Bladder movements- Regular

       Regularly consumes 250ml of alcohol since the         one year. 

     

Drug history

      No drug history

General examination 

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

Pallor- absent

Icterus- absent

Cyanosis- Absent

Clubbing- Absent

Lymphadenopathy- Absent

Edema-Absent

Vitals:

Temperature- 97.6 F

PR- 90/m

BP- 110/90 mm Hg

RR- 20/min

SpO2- 95% @ RA

Systemic Examination:

P/A: Soft, Non tender, No palpable organomegaly

Bowel sounds heard. 

CVS- S1,S2 sounds present. No murmurs

RS- BAE+, NVBS heard

CNS- NAD

Provisional Diagnosis: 

Grade 3 alcoholic fatty liver 

Treatment given:

 INJ. THIAMINE 1Ampoule 100U IN normal saline i.v TID

 TAB. LIBRIUM 25 mg PO/OD

  INJ.OPINEURON 1Ampoule 100U IN normal saline i.m. OD

  INJ.LORAZEPAM 1Ampoule i.m. SOS

  INJ.ZEFOR 4mg I.v. BD

  TAB.PCM 650mg PO/SOS

  INJ.PAN 40MG I.v BD

  TAB.MECUPAN 40MG BD

  TAB. BACFEN 20MG BD

  TAB.BENFOMET PLUS BD

Diagnosis

ALD is one of the commonest causes of liver disease. ALD comprises spectrum which include fatty liver, AH, cirrhosis with or without AH with its complications like ascites, hepatic encephalopathy and HCC. Diagnosis of ALD requires good reliable history of significant alcohol abuse and excluding other causes of liver disease. AH with alcoholic cirrhosis is one of commonest of acute on chronic liver failure with associated organ failure and high short-term mortality. These patients present with rapid onset jaundice, ascites, hepatic encephalopathy and acute kidney injury. Liver biopsy is generally not required in majority of patients except when history of alcohol intake is not reliable, associated infection with viral disease, obesity or other hepatotropic or non-hepatotropic insult and treatment protocols under trials when definitive diagnosis of AH is required.