41YEAR OLD MALE WITH PORTAL HYPERTENSION WITH CIRRHOTIC LIVER WITH CHRONIC ALCOHOLISM

Dr.ABDUL RAHEEM (INTERN)
Dr.ASHFAQ (INTERN)
Dr.GNANADHA (INTERN)
Dr.SRAVYA (INTERN)
Dr.CHETANA (INTERN)
Dr.NAVYA (INTERN)

Dr.VAMSHI ( PG1)
Dr.SAI CHARAN(PG1)
Dr.SUSMITHA (PG2)
Dr.ADITYA (PG3)
Dr.PRANEETH(PG3)
Dr.PRAVEEN NAIK (ASS.PROF)(  duty on call 1)
Dr.RAKESH BISWAS (PROF.AND HOD) ( duty on call 2)

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.

Here is a case i have seen:
A 41 year old man presented with a 4 month history of yellow discoloration of eye whites. 

The patient was absolutely normal 4 months ago when he first started noticing yellow discoloration of both his eye. He also had afternoon fatigue which improved with rest. The patient also reported a 1 month history of distension of abdomen which was followed by pedal edema and now facial puffiness. The patient denies itching or constipation but he occasionally has pitch black solid stools. He also reported dyspnea in the last 10 days. No PND or Orthopnea. No exercise intolerance, no cold hands, no palpitations, no cough or expectoration, no wheeze, no nocturia or daytime somnolence. He also reported frothy urine and occasional hematuria. No dysuria, oliguria, no polyruria. He currently has lemon yellow discoloration of urine. 

The patient's work involves heavy weight lifting and he has been having alcohol use since age 11. Initially consumed a glass of 'Gudumba' and about 10 years later (after it was illegalised) he started consuming 90ml of Imperial Blue which has now increased to 180ml everyday. He is a never smoker and reports no other recreational drug use. His bowel and bladder habits are intact and his diet is fairly mixed. However since the last 10 days, he reports loss of appetite and he also told us that in 4 months, the patient lost nearly 20 kgs involuntarily. H/o herbal medicine for 10days. No H/o Hypertension, diabetes mellitus,asthma, thyroid, tuberculosis.

Provisional Diagnosis - Portal Hypertension secondary to Cirrhosis of Liver associated with Chronic Alcohol Use Disorder. 

Coronary Artery Disease leading to HFpEF.
O/E
Patient is conscious,well orientated to time,place, person.
Icterus+, bilateral paedal edema present up to the knee (grade-3).
No signs of pallor,clubbing,cyanosis, generalized lymphadenopathy.
Vitals-
Temperature- 98.3F
PR- 86bpm
Bp-130/80 mm of Hg
RR- 24Cpm
Per Abdomen:
 inspection-
Distended abdominal veins present.
Palpation-
soft, distended abdomen.
Tenderness present in right left lumbar region.abdominal girth - 94cm.
Mild to moderate spleenomegaly present.
Percussion- hepatomegaly present(18cm).
Auscultation- bowel sounds heard.
shifting dullness present. 
CVS: S1, S2 heard.jvp mild elevated.

Pancystolic,crescendo- decrescendo murmur best heard in the right and left parasternal borders.
RS : BAE Present.gynaecomastia present.
Upper segment morethan lower segment.(21cm- 18cm).
CNS - NFND
Diagnosis:Portal Hypertension secondary to Cirrhosis of Liver associated with Chronic Alcohol Use Disorder. 
Investigatuons
Ecg-
CBP-
 Hb- 9.1gm/dl
 TLC-3,400 cells/cumm
 PLATELETS-1.20 Laks/cumm
Blood urea-36 mg/dl
Serum creatinine-0.8 mg/dl

Rx on day 1(25/1)
Tab. CARDIVAS- 3.125Mg PO /OD
Tab. LASIX -40 mg PO /BD
Syrup LACTULOSE 15 ml PO/ BD
Tab. A-Z PO/ OD
Tab. FERIVENT XT PO/ OD
Plan for upper GI endoscopy on Friday
On day 2 (26/1)
S- 
 Yellowish discolouration of sclera : still present
abdominal distension : still present 
pedal edema : subsided
facial puffiness: subsided
Appetite improved 
no fresh complaints 

O -
BP: 100/70mm hg
PR: 88 bpm
CVS: S1, S2 heard
RS: clear
Abdomen: soft, distended abdomen 
shifting dullness present. 
Tenderness present in right left lumbar region. 
CNS-NFND
Investigations
Serology
CUE-pale yellow colour,clear,acidic,
2-3 pus cells,2-3 epithelial cells. no albumin,sugar,bile pigments,bile salts,RBC,casts,amorphous deposits.

P-
Tab. CARDIVAS- 3.125mg PO /OD
Tab. LASIX -40 mg PO/ BD
Syrup LACTULOSE 15 ml PO/ BD
Tab. A-Z PO /OD
Tab. FERIVENT XT PO/ OD
BP, PR, Temp monitoring 4th hourly

Plan for upper GI endoscopy on Friday
On day 3(27/1)
S- 
 Yellowish discolouration of sclera : still present
abdominal distension : decreased
pedal edema : subsided
facial puffiness: subsided
Appetite improved 
no fresh complaints 

O -
BP: 110/70mm hg
PR:  80 bpm
CVS: S1, S2 heard
RS: clear
Abdomen: soft, distended abdomen 
shifting dullness present. 
Tenderness present in right left lumbar region. 
CNS-NFND
Investigations
FBS- 92 mg/dl
PLBS-136mg/dl
HBA1C- 6.7%
USG-
 Surface irregularity with nodular liver portal vein - increased diameter,increased PSV and lost normal undulative pattern.F/S/O portal hypertension.
 Gross spleenomegaly.
 Moderate ascites.
 F/S/O CHRONIC LIVER DISEASE.
Rx-
Tab. CARDIVAS- 3.125mg PO /OD
Tab. LASIX -40 mg PO /BD
Syrup LACTULOSE 15 ml PO/ BD
Tab. A-Z PO/ OD
Tab. FERIVENT XT PO /OD
BP, PR, Temp monitoring 4th hourly
Ascitic fluid tapping done (500ml)
Investigations:
Ascitic fluid analysis-
Cell count: clear,yellow,total cells-22/cumm, neutrophils-30%,lymphocytes-70%.RBC - few.
Protein- 0.5 g/dl
Sugar- 180 mg/dl
LDH-145 IU/L
Ascitic albumin- 0.26 gm /dl
Serum albumin-2.44 mg/dl
SAAG-2.18
Plan for upper GI endoscopy on Friday

On day 4(28/1)
S- 
 Yellowish discolouration of sclera : still present
abdominal distension : decreased
pedal edema : subsided
facial puffiness: subsided
Appetite improved 
no fresh complaints 

O -
BP: 110/80mm hg
PR:  78bpm
CVS: S1, S2 heard
RS: clear
Abdomen: soft, distended abdomen 
shifting dullness present. 
Tenderness present in right left lumbar region. 
CNS-NFND
Investigations-
2decho-
Rx-
Tab. CARDIVAS- 3.125mg PO /OD
Tab. LASIX -40 mg PO/ BD
Syrup LACTULOSE 15 ml PO /BD
Tab. A-Z POOD
Tab. FERIVENT XT PO/ OD
BP, PR, Temp monitoring 4th hourly

Plan for upper GI endoscopy on Friday
On day 5 (29/1)
S- 
 Yellowish discolouration of sclera : still present
abdominal distension : increased
pedal edema : subsided
facial puffiness: subsided
Appetite improved 
no fresh complaints.

O -
BP: 110/80mm hg
PR:  80bpm
CVS: S1, S2 heard
RS: clear
Abdomen: soft, distended abdomen 
shifting dullness present. 
Tenderness present in right left lumbar region. 
CNS-NFND
Investigations:
LFT-
 TB- 20.16mg/dl
 DB-14.37 mg/dl
 AST-109 IU/L
 ALT-48IU/L
 ALP-234IU/L
 TP-6 gm/dl
 Albumin-2.3gm/dl
 A/G :0.64 
Rx-
Tab. CARDIVAS- 3.125mg PO /OD
Tab. LASIX -40 mg PO /BD
Syrup LACTULOSE 15 ml PO/ BD
Tab. A-Z PO /OD
Tab. FERIVENT XT PO /OD
BP, PR, Temp monitoring 4th hourly

Plan for upper GI endoscopy on Friday
On day 6 (30/1)
 S- fatiguability +
     Yellowish discolouration of sclera : present.
Abdominal distension increased.

O -
BP: 110/70mm hg
PR: 84 bpm
CVS: S1, S2 heard
RS: clear
Abdomen: soft, non tender distended abdomen 
CNS-NFND
A- PORTAL HYPERTENSION WITH CIRRHOTIC LIVER SECONDARY TO CHRONIC ALCOHOLISM. 
P - ascitic fluid tapping done- 1.5 litre.
500 ml NS IV Given.
1.Tab. CARDIVAS- 3.125mg PO / OD
2.Tab. LASIX -40 mg PO / BD
3.Syrup LACTULOSE 15 ml PO / BD
Tab. A-Z PO / OD
Tab. FERIVENT XT PO / OD

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