General medicine elog

G.Pranay kumar rao
3rd semester

This is 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 patients clinical problems with collective current best evidence based inputs.This e-log also reflects patients centered learning portfolio.

Case in brief-
A 44yr male Patient came to casuality with yellowish discolouration of sclera . 

Cheif complaints
• Abdominal distension since 5yrs gradually developed.
• Bilateral pedal edema since 20days extending upto knees
• Yellowish discolouration since 20days 
• Vomiting- bulk 2-3 episodes per day 

History of present illness
• B/l lower limb edema extending upto knee since 20days .
• Yellowish discolouration of sclera since 20days . 

History of past illness
• 2-3episodes of non projectile food in content ,non bilious ,
• Consumes 90ml whiskey 4times a day since 5months due to alcoholism since 10yrs . 

Treatment history 
• Yellowish discolouration of sclera since 1yr which is resolved with Tab.UDILIV ,TAB LIV 52mg. 

Personal History
• Married
• Farmer by occupation 
• Appetite is low 
• Nonvegetarian
• Bowels -regular
• Micturition normal
• No H/o allergies 
Family History

Not significant 

Vitals
PR- 82bpm
BP-110/70mmHg
Sp o2%-98%
GRBS-174mg%


General examination
• Consious ,coherent and cooperative
• Pallor 
• No cyanosis
• No icterus
• No clubbing
• No lymphadenopathy 
• B/l pedal edema 
• No malnutrition 
• No dehydration
Pallor
Abdominal distension





Systemic examination 

1. Respiratory system
     BAE-+

     S1, S2 Heard
3.PA 
     Soft 
3.CNS
      Intact 

INVESTIGATIONS- 

13/8/21
USG abdomen
Hemogram
Prothrombin time
bleeding and clotting time
LFT
APTT
RFT

14/8/21
Complete urine examination
2d echo
Ecg
HBsAg Rapid
HIV RAPID TEST


Provisional diagnosis
Alcoholic Hepatitis 

Treatment 

13/8/21
• Inj.THIAMINE 1amp in 100ml NS -IV TID
• Inj.Pantop 40mg IV -OD
• Inj. ZOFER 4mg IV TID
• TAB.UDILIV 300mg BD
• Tab.lasilactone 20/50mg BD
• Syp.Lactulose 15ml H/S
• Syp.Potchlor 10ml -TID
• Bp/ PR /Temp/Spo2 monitoring 

14/8/21
• Inj.THIAMINE 1amp in 100ml NS -IV TID
• Inj.Pantop 40mg IV -OD
• Inj. ZOFER 4mg IV TID
• TAB.UDILIV 300mg BD
• Tab.Viboliv 500mg TID
• Bp/ PR /Temp/Spo2 monitoring 

15/8/21
• Inj.THIAMINE 1amp in 100ml NS -IV TID
• Inj.Pantop 40mg IV -OD
• TAB.UDILIV 300mg BD
• Tab.Viboliv 500mg TID
• Tab.Pentoxifylline 400mg TID
• Bp/ PR /Temp/Spo2 monitoring

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