35 YRS OLD MALE WITH HYPOGLYCEMIA AND ALTERED SENSORIUM SECONDARY TO HEPATIC ENCEPHALOPATHY

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.
35 yrs old male Patient brought to casualty with complaints of unresponsiveness since 4 am morning
Yellowish discoloration of sclera and eyes since 6 months
Abdominal distension since 1 week
Pedal edema since 1 week

HOPI : patient was apparently normal 6 yrs (2014) back then he developed jaundice with altered behaviour went to local hospital and diagnosed with CLD
Patient was chronic alcoholic since 20yrs
In 2014 patient visited hospital with c/o b/l pedal edema, jaundice and abdominal distension and was diagnosed with CLD
Since then patient was on irregular medication and continued taking alcohol intermittently
Since 4 days, patient has c/o fever subsided now used 4 tablets of DOLO
C/o loose stools 4-5 episodes per day,no h/o malena , pain abdomen
C/o nausea and loss of appetite
C/o altered sensorium since today morning not responding to commands
No h/o weakness and no h/o involuntary movements

PAST HISTORY: 
    N/K/C/O HTN/DM/ASTHMA/CAD
      K/C/O PULMONARY KOCHS 15 YRS BACK USED ATT

General examination :

Pt is conscious,coherent and cooperative.thin built and malnourished.

No pallor
ICTERUS PRESENT
No clubbing
No lymphadenopathy
No edema
 
Vitals :

Temp : Afebrile
BP : 100/80 mm Hg
PR : 105 bpm
RR : 25 cpm
GRBS : 33 mg / dl
SpO2 : 91 % @ RA

Systemic Examination :
CVS : S1S2 + , No murmurs
RS : BAE + , NVBS +
P/A : Soft , Nontender , BS +
CNS : Response to pain
GCS--E2V1M2
Provisional diagnosis : 

HEPATIC ENCEPHALOPATHY SECONDARY TO LIVER FAILURE
RECURRENT HYPOGLYCEMIA
K/C/O CHRONIC LIVER DISEASE WITH GROSS ASCITES AND SPLENOMEGALY(PORTAL HTN)-PRECIPITATED BY PCM USAGE
GRADE 2 OESOPHAGEAL VARICES
CLINICAL IMAGES::
INVESTIGATIONS::
PLAN OF TREATMENT:
INJ.LASIX 20 MG/IV/BD
TAB.ALDACTONE 50 MG/RT/BD
INJ.25% DEXTROSE 100ML/IV/SOS IF GRBS<60 MG/DL
SYP. LACTULOSE 20 ML/PO/BD
INJ. THIAMINE 1 AMP IN 100 ML NS/IV/TID
GRBS CHECK HOURLY
BP/PR/TEMP CHARTING HOURLY
T. UDILIV 300 MG/ RT/BD
SYP. HEPAMERZ 2 TBSP/RT/BD
T RIFAXIMIN 550 MG /RT/BD
ENEMA 12 TH HOURLY
STRICT I/O CHARTING
INJ.CEFOTAXIME 2G /IV/BD


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