Combined Clinic (GI)BY KYAW KHAN ZAW, KAUNG THET HAN & KYAW SAN LINFROM FINAL PART 2, MEDICINE POSTING AT YGH, WARD 1 - 2

History TakingBY KYAW KHAN ZAW, ROLL NO. 17

Patient Identification•Name: UNM•Age: 46 years•Race: Burmese•Region: Buddhist•Address North Okkalar•Occupation: Retired engineer•Marital status: Divorced

Admission•Date of Admission: 13th April, 2015•Time of Admission: 10 AM•Ward admitted : YGH, Ward 1 – 2

Chief complaint•Fever off and on x 2 months•Yellow discoloration of skin & sclera x 2 months•Abdominal Distension and oedema x one and half month

History of present illness

Yellow discolorations of skin & sclera•Noticed by himself while washing his face•Duration : 2 months•Onset : Gradual•Progression : Progressive•Urine colour: High colour•Stool colour : Normal

For haemolytic jaundice•No family history of blood diseases/ blood transfusion

•No associated pallor according to the patient

For viral hepatitis•No prodromal symptoms such as anorexia, nausea, vomiting, distaste, rash, joint and muscle pain.

•No outbreak of VH - A nearby.

•No risk factors for VH – B/C/D such asoBlood tansfusion, ounsterile injection, o tatooing, oear-piercingo sexual promiscuity

•Vaccination (-)

For leptospirosis•No eyeball tenderness•No abdominal pain, decreased urine output•No chest pain•No cough with sputum, haemoptysis•No muscle and joint pain•No occupational risk for getting Leptospira infection

For Hepatic amoebiasis•No history of repeated dysentery without proper treatment

History of alcohol drinking •Type : Whisky

•Duration : 2 years

•Amount : 3 – 4 bottles/day

For post hepatic jaundice•No pruritus•No history of passing worms•No risk factors for gall stones such as being age over 50, fat, female gender, being fertile & flatulence

Fever•Duration : 2 months•Character : Remittent•Severity : high fever•No chill and rigor•Travelling history (+)•History of TB contact (-)•Risk factors associated with HIV infection (-)•Abdominal pain (-)

Abdominal distention and Oedema

•Onset : Gradual•Duration : one and half month•Site of 1st appearance : Legs•Progress and rate : Progressive and Gradual•Severity : Not associated with breathlessness, orthopnoea•Amount of urine : Normal•Aggravating Factors : unknown•Relieving Factors : Diuretics

For cardiac oedema•Dyspnoea (-)•Orthopnoea (-)•PND (-)•Palpitation (-)•Chest pain (-)

For chronic renal disease•Oliguria (-)•Puffy face (-)•Loin pain (-)

For nutritional oedema•Chronic diarrhea (-)•Vomiting (-)•Anorexia (-)•Dysphagia (-)•Dyspepsia (-)

To assess the complicationsFor Hepatic Encephalopathy•Disordered sleep rhythm (+)•Slurring of speech (-)•Disorientation (-)•Confusion (-)

For portal hypertension•Abdominal distention (+)•Haematemesis and melaena (-)•Bleeding piles (-)

For spontaneous bacterial peritonitis•Fever (+)•Abdominal pain (-)

For hepatorenal syndrome

•Oliguria (-)

System Review•Respiratory : Cough(-), Sputum(-), Haemoptysis(-),

wheeze(-), Stridor(-)•CVS : Dysnoea on exertion(-), Cyanosis(-)

•Renal : Normal Urine Output, Normal urine colour•CNS : Fit(-)

Past Medical History•Hepatitis (+)

•No past history of blood disorder requiring transfusion•Hypertension (-)•Diabetes Mellitus (-)•Ischaemic heart disease (-)•TB (-)

• On March 2015, admitted to North Okkalar General Hospital for 5 days for the similar complaints.• Went to 2 follow up after discharge from NOGH.• On 2nd May. admitted to Aung Yadanar Polyclinic.

Past Surgical History•No past surgical history.

Personal History•Alcohol drinking (+)• Smoking (+)•Betal chewing(+)

Drug History•No known drug allergy.• No history of taking drug apart from those prescribed by the hospital.•There is no history of taking drugs that can cause haemolysis such as sulphonamides and dapsone.•No history of taking hepatotoxic drugs such as INH and rafimpicin, methotrexate, prolonged used of NSAIDs and chlopromazine, etc•No history of taking indigenous medicine.

Family HistoryNo family history of•Viral hepatits•Hepatocellular carcinoma•TB contact

Physical ExaminationBY KAUNG THET HAN, ROLL NO. 12

General ExaminationGeneral observationAge-middle ageSex-gentlemanConscious level-well consciousComfortable position-lying confortable on the bedDyspnoeic-not dyspnoeicBody Build-average

General ExaminationAfebrileFace: bilateral parotid swelling (+), thalassaemic facies (-)Eye: jaundice (+), Conjunctival haemorrhage (-), anaemia (-), Kayser Fleischer ring (-), eyeball tenderness (-), xanthelasma (-)Nose:epistaxis(-)Mouth: oral thrush (+), fetor hepaticus (-), gum bleeding (-), angular stomatitis (-), glossitis (-)Neck:visible pulsations (-), lymph node enlargement (-)

General ExaminationHands: Clubbing (-), Leukonychia (+), koilonychia (-), palmer erythema (+), Dupuytren’s contracture (-), flapping tremor (-), Bruises (+), pigmentation of palmer creases & knuckles (-), tattoo marks (-), needle tracks (-)Legs: Bilateral pitting pedal odema (+), Clubbing (-)Chest: gynaecomastia (-), axillary hairs are sparse, spider naevi (+), tattoo marks (-)

Abdominal examination (Inspection)The shape of the abdomen is distended.The flanks are full. Umbilicus is flat.It moves with respiration.There is no scar, no dilated veins.No visible mass and peristalsis.Hernia orifices are intact.

Abdominal examination (Palpation) Light palpationThe abdomen is soft.Normal temperature.No tenderness, rigidity, guarding.No palpable mass.

Abdominal examination (Palpation) Deep PalpationLiver: size-about 4cm from the right coastal margin, tenderness(-)Spleen: is not enlargedKidneys are not ballotable.

Abdominal examination (Percussion)Liver dullness is increased up to the right 4th intercostal space along the mid-clavicular lineUpward enlargement of liver (+)Splenic dullness is absent Free fluid: Shifting dullness (+)

Abdominal examination (Auscultation)Bowel sound (+)Liver Bruit (-)Splenic Rub (-)

Digital Rectal Examination Rectal varices (-)

Bedside TestsNo constructional apraxia

System ReviewCVS system – no cyanosis, no cardiomegaly, no added soundsRespiratory system –no apical crepitations, no bilateral basal crepitations

Provisional diagnosis Chronic liver disease – cirrhosis of liver most probably due to alcohol with ascites

Investigations & TreatmentBY KYAW SAN LIN, ROLL NO. 21

Investigations

Liver Function Test (LFT)Serum Total Bilirubin 250.7 μmol/L (raised)Serum Alkaline Phosphatase 113 U/L (normal)

Liver EnzymesALT 13 U/L (normal)AST 56 U/L (raised)

Total & Differential Protein (T & DP)Total protein 60 g/L (reduced)Albumin 23 g/L (reduced)Globulin 37 g/L (raised)A:G ratio reversed

Coagulation testsPT (Prothrombin time) 35 sec (prolonged) (normal control is 12.0 sec)INR (International Normalized Ratio) 2.83

ISI = International Sensitivity Index of thromboplastin

Full Blood CountHaemoglobin concentration 7.1 g/dl (anaemia)Haematocrit 19.4% (low)MCV 72.4 fL (microcytic)MCH 26.5 pg (normal)MCHC 36.6 g/dL (normal)

Full Blood CountTotal WBC Count 19.15 x 103/μL (Leucocytosis)Neutrophil count 13.47 x 103/μL (neutrophilia)Neutrophil % 70.3% (normal)Lymphocyte count 3.25 x 103/μL (normal)Lymphocyte % 17% (reduced)

Full Blood Count Monocyte count1.76 x 103 /μL (monocytosis) Monocyte % 9.2% (normal) Eosinophil count0.57 x 103 /μL (eosinophilia)

Eosinophil % 3.0% (normal) Basophil count 0.10 x 103 /μL (normal) Basophil % 0.5% (normal)

Full Blood CountPlatelet count 183 x 109/L (normal)

Blood Film ExaminationRBC: Hypochromic microcytic with anisopoikilocytosisWBC: Neutrophil leucocytosisPlatelet: Adequate

Serum Urea, Creatinine & ElectrolytesUrea 4.1 mmol/L (normal)Creatinine90 μmol/L (normal)Na+ 129 mmol/L (hyponatraemia)K+ 4.02 mmol/L (normal)Cl- 100.6 mmol/L (normal)Bicarbonate 20.3 mmol/L (reduced)

Urine RESpecific gravity 1.010pH 7Leucocyte negativeNitrite negativeProtein negative

Urine REGlucose negativeKetone negativeUrobilinogen normalBilirubin negativeBlood negative

Other testsESR 60mm after 1st hour (raised)HBsAg negativeAnti HCV negativeRBS 131 mg/dlCXR (PA) cardiomegalyECG NADOGD scopy planned to do next week

Child – Pugh ClassificationSerum Bilirubin >50 μmol/L 3Albumin <28 g/L 3PT >6 sec longer than normal 3Ascites mild 2Encephalopathy none 1Total Score 12 = Child’s C1st year survival 42%5th year survival 20% Refer to Davidson’s Principles & Practice of Medicine

22nd Ed. Pg. 944 for the full scoring system.

Maddrey’s discriminant function (DF)DF = [ 4.6 x Increase in PT (sec) ] + Bilirubin (mg/dL) DF = 111> 32 implies severe liver disease with a poor prognosis.

Definitive DiagnosisChronic liver disease – cirrhosis of liver most probably due to alcohol with ascites

Treatment

Abstinence of alcoholcornerstone of therapy for patients with alcoholic liver disease

Treatment of AscitesBed rest in supine positionSalt, water restrictionPO Spironolactone (Aldactone®) 4 tablets odIV Furosemide (Lasix®) 40 mg 12 hrly

Treatment of CoagulopathyInfusion of FFP 1 units daily for 3 daysIV Vitamin K 1 ampoule od

Prophylaxis of Hepatic EncephalopathyPO Rifaximin (Hepaxime®) 1 tablet bd

Treatment of Spontaneous Bacterial Peritonitis (SBP)IV Metronidazole 500 mg 8 hrlyIV levofloxacin 500 mg odIV Piperacillin/tazobactem 4.5 g 8 hrly

Supportive TreatmentIVI dextrose water + Pabrinex® 1 pairPO DL – Methionine, choline & vitamins (Neutrosec®) 1 tablet bdPO Arginine 1 tablet bdPO Protec® tablet 1 bdPO Live Up® 1 tablet odPO Hepacel® 1 tablet bd

Supportive TreatmentPO Thiamine (Bevit®) 1 tablet bdPO slow K 2 tablets tdsPO Ursodeoxycholic acid (Udihep®) 1 bd

Expert Opinion & Management Shown to Liver Medical Unit, YSH

Thank you very much for listening!!! Any questions???