59 Gnana Prasanna Engala
40 yr old male with jaundice and pruritis with type 2 diabetes mellitus
February 16 , 2023
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Name : E. Gnana Prasanna
Roll no :01
Admission no :166029
Chief complaints:
Yellowish discolouration of eyes since 20 days
Itching all over the body since 20 days
History of presenting illness:
Patient was apparently asymptomatic 20 days back then he developed yellowish discolouration of eyes and greenish yellow discolouration of urine
Loss of appetite present
Relieved on medication which was prescribed by local RMP
Loss of weight from 52 kg to 47 kg in 20 days
Abdominal tightness present and relieved on medication
No h/o bloating no h/o abdominal pain, constipation,
Incomplete evacuation of stools since 20 days passing pale coloured stools
No h/o fever, vomiting, diarrhoea
No decrease in urine output
No abdominal distension
Itching all over the body present
History of usage of herbal medication usage for 6 days which aggravated yellowish discolouration and pruritus so stopped using them
Past history:
Past medical history known case of diabetes mellitus since 4 months on Tab.Glimi-M1( METFORMIN 1000mg+GLIMIPRIDE 1mg)
Not a k/c/o HTN CVA CAD epilepsy TB
Past surgical history
No significant past surgical history .
Personal history:
Diet mixed
Appetite decreased relieved on medication
Sleep adequate
Bowel and bladder regular
No known allergies
Habits:regularly takes alcohol 90ml/day stopped 1 month back
Family history: no significant family history
General examination:
Patien is conscious coherent cooperative
Icterus present
No pallor cyanosis clubbing lymphadenopathy edema
Vitals:
PR:80bpm
BP:100/60 mmHg
RR:16 cpm
Spo2:98%
GRBS:238mg/dl
CVS examination:
S1,S2 heard
No additional sounds heard
RS examination: position of trachea central
BAE +, NVBS +
Per abdomen:
Shape of abdomen scaphoid
No tenderness
No palpable mass
Liver palpable:dullness on percussion at 6 th IC space ,lower border 4-5 below costal margin
Liver span 16cm
Investigations:
USG: no sonological abnormality
Chest X-ray:
ECG:
2D echo:
Trivial TR, no MR/AR
No RWMA, no AS/MS
Good LV systolic function
No diastolic dysfunction no PAH/PE
Gastroenterologist opinion was taken I/v/o alcoholic liver disease they advised MRCP
Psychiatry referral fine I/v/o alcohol consumption impression:alcohol dependence syndrome currently abstinent
Dermatologist referral I/v/o pruritus
Diagnosis: pruritus secondary to hyperbilirubinemia
Tab. TECZINE 10 mg od/sos
Liquid paraffin/ cebhydra lotion LA/BD
Provisional diagnosis:choleatatic jaundice with pruritus with type 2 DM
Treatment:
Day-1(16/2/23)
1.T.UDILIN 300 mg
2.syp.HEPAMERZ 10 ml po od
3.T.LEVOCET 10mg po h/s 9.00 pm
4.T.GLIMIPERIDE 1 mg po od
5.T.METFORMIN 1000mg po od after breakfast
6.pulse rate , BP , RR, temperature monitoring 4th hourly
Advice at discharge
T.GLIMIPERIDE 1 mg po od
T.METFORMIN 1000mg po od after breakfast
T.HEPTAGON po/bd x1 week
T.BRONAC 60 mg po/ BD x1 week
Cholestyramine oral suspension po/BD x1 week
syp.HEPAMERZ 10 ml po od x 1 week
