A 65 year old with alcoholic liver disease with acute hepatitis

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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 - 

Distension of abdomen since two months 

B/l pedal edema since one week

Sob on walking short distance since 10 days

Yellowish discolouration of eyes since 10 days 

 History of presenting illness -

Pt was apparently asymptotic 2 months back then he c/o distended Abdomen not associated with pain,vomiting fever . He c/o sob while walking for short distance. No h/o chest pain, sweating no h/o palpitations, no h/o burning micturation, 

there is h/o discolouration of urine to red 

H/o passing hard stool since one month

H/o Malena present 

Past history-

H/o unilateral right leg swelling since 2010 which is on and off 

K/c/o Dm since 6 months ( on medication - metformin + glimipride )

N/k/c/o - HTN, EPILEPSY, CAD,CVA

Dialysis done in 2010 I/v/o 

Personal history- APPETITE: NORMAL 

DIET: MIXED

SLEEP: ADEQUATE 

BOWEL: Normal , hard stools

BLADDER: NORMAL 

NO ALLERGIES 

ADDICTIONS - ALCOHOL 90ml twice or thrice in a month since 30 years

FAMILY HISTORY: 

NO H/O SIMILAR COMPLAINTS IN THE FAMILY 

General examination-  

THE PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE

MODERATELY BUILT AND NOURISHED 

SIGNS OF PALLOR, ICTERUS 

No CYANOSIS, CLULBBING of fingers , EDEMA of feet ( non pitting )   

VITALS: 

TEMP: AFEBRILE 

PR: 68 BPM 

RR: 16 CPM 

BP: 110/70 MM HG

SPO2: 95% @ RA 

GRBS: 114 MG/DL 

CVS: S1, S2 HEARS, NO MURMURS 

RS: BAE+, NVBS 

TRACHEA: CENTRAL 

NO DYSPNOEA AND WHEEZE 

NO RHONCHI 

ABDOMEN:  TENDER, SOFT, DISTENDED, UMBLICAL HERNIA PRESENT

LIVER AND SPLEEN NOT PALPABLE 

BOWEL SOUNDS NOT HEARD 

FREE FLUID PRESENT

CNS: 

LEVEL OF CONSCIOUSNESS: CONSCIOUS, ALERT 

SPEECH: NORMAL

NECK STIFFNESS ABSENT 

KERNINGS SIGN ABSENT 

CRANIAL NERVES: NORMAL 

MOTOR SYSTEM: NORMAL 

SENSORY SYSTEM: NORMAL 

GCS: 15/15 E4V5M6 

TONE: 

UL: INCREASED IN BOTH 

LL: INCREASED IN BOTH 

POWER: 

UL: BOTH 4/5

LL: BOTH 4/5

REFLEXES:             RT              LT

B:                           +2              +2

T:                           +2              +2

S:                           +1              +1

K:                           +2             +2

A:                           +2              +2

PROVISION DIAGNOSIS - ALCOHOLIC LIVER DISEASE WITH ACUTE HEPATITIS 

INVESTIGATION 

HB: 8.7

TLC: 5200

N: 54% 

PLT: 1.7

TB: 9.45

DB: 8.20

SGOT: 532

SGPT: 841

ALP: 418

TP: 6

ALB: 3.59

A/G: 1.49

CREAT: 1.3

NA: 137 

K: 4.0 

CL: 104 

CA: 9.7

Uric acid 5.4

Urea 41 

CUE: 

ALB: NIL 

PUS CELLS: 2-3 CELLS 

Rbs - 104

USG- 

MINIMAL INTER BOWEL FLUID

B/l grade1 RPD CHANGES

LEFT SIMPLE RENAL CORTICAL CYST

UMBILICAL HERNIA OMENTUM AS CONTENT

GRADE 1PROSTATOMEGALY

GRADE 1 FATTY LIVER

DIFFUSE GALL BLADDER EDEMA AND PARTIALLY DISTENDED GALL BLADDER

TREATMENT 

TAB UDILIV 300mg po/bd

TAB HEPAMERZ PO/bd

SYP LACTULOSE

TAB RIFAGUT 550mg

INJ HAI 

TAB ECOSPRIN AV