36 year old man with yellowish discoloration of eyes and urine since 3months

A 36 year old male who is a master cook by occupation came to opd with complaints of yellowish discoloration of eyes and urine since 3 months

HOPI: patient was apparently normal 1 year back ,then he developed lower back ache ,diagnosed with renal calculi and was operated.

C/o fever since 3 months
        Insidious in onset
        Gradually progressive
        Subsides on its own
        More during nights
C/o nausea since 3 months
C/o vomitings ( 4 -5 episodes) food particles as content
H/o weight loss since 1month
C/o pain abdomen intermittently and was admitted in an hospital thrice till now and diagnosed with chronic pancreatitis
H/o usage of Herbal medicine 1 month back ,6 times/day for a week
H/o pedal edema and abdominal distension 1 month back , used medication for this in Nalgonda

PAST HISTORY:
Alcoholic and tobacco chewer since 20 years
H/o Renal caliculi and was operated for that .

PERSONAL HISTORY :
Thin built
Appetite lost
Regular alcoholic and tobacco chewer,
stopped 3 months back
Bowel movements are Regular

FAMILY HISTORY: Not significant

GENERAL EXAMINATION:
ICTERUS present
NO PALLOR, CYANOSIS,CLUBBING, LYMPHADENOPATHY,EDEMA

Patient is conscious, coherent, cooperative
Temperature : 98.5°f
BP: 80/60mmhg
PR: 99bpm
RR: 18CPM
SPO2: 99@room air
CVS:S1S2+ no murmurs
RS: NVBS+ clear

PER ABDOMEN:

INSPECTION: scaphoid abdomen, umbilicus inverted,no engorged veins,no sinuses
PALPATION:  LIVER PALPABLE ,No tenderness, no palpable mass .
PERCUSSION:Hepatomegaly + ,LIVER span 20cm.
AUSCULTATION: Bowel sounds +

CNS: NAD

INVESTIGATIONS:

DIAGNOSIS: ACUTE DECOMPENSATED LIVER DISEASE

TREATMENT:
1. Inj.THIAMINE 2amp in 500ml NS/IV/TID over 2hrs
2.INJ.PANTOP 40MG/IV/OD
3.INJ.ZOFER 4MG/IV/BD
4.INJ.OPTINEUROB 1amp in 100ml NS /IV/OD
5.INJ.VIT.K 1amp/IV/OD
6.INJ.MEROPENUM 1GM /IV/BD
7.TAB.DOILIN 300MG /PO/BD
8.TAB.RIFAGUT 550MG /PO/BD
9.SYRUP .LACTULOSE 10ML /PO/OD
10.SOAP WATER ENEMA
11.ABDOMINAL GIRTH MEASUREMENT
12. FEVER CHARTING
13.MONITOR VITALS

DAY:2

S :
No fever spikes
No fresh complaints

O :
Pt is C/C/C
Temp : afebrile
BP : 110/50
PR : 74 bpm
RR : 20 cpm
CVS : s1 s2 heard, no murmurs
RS : NVBD + , No crepts
PA : Soft, hepatomegealy + , 22 cm liver span
        No engorged veins/ distension
GRBS : 284 mg/dl

A :
ACUTE DECOMPENSATED LIVER DISEASE WITH CONJUGATED HYPERBILIRUBINEMIA

P :
1. INJ.  MEROPENEM 1 GM/IV/BD ( D3 )
2. INJ.  PANTOP 40 MG /IV/ OD
3. INJ.  ZOFER 4 MG /IV/SOS
4. INJ.  THIAMINE 2 AMP IN 500 ML NS /IV/TID
5. INJ.  OPTINEURON 1 AMP IN 100 ML NS /IV OD

    APRAXIA CHARTING