45yrs old male with increased involuntary movements ( tremors)

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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 in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment

45 yr old male patient came with c/c of  

-increased  involuntary movements (tremors) ,since 1 day.

-increased drowsiness since 1 day.

History of presenting of illness- 

patient was apparently asymptomatic 8months back then he developed pedal edema, shortness of breath,distension of abdomen, itching of skin,jaundice and is diagnosed to have "chronic decompensated liver disease" with portal HTN with Ascites with grade 1 esophageal varcies with Times corporicet with HTN  since 3yrs. 

He was admitted in our hospital on 7/1/2023 gTreatment given was :-

 1.salt restriction less than 2gm /day

2.fluid restriction less than  1.5l /day

3.Tab .lasix 40mg PO /BD for 10days 

4.Tab. Spririnolactone 25mg PO /OD for 10days.

5.syrup.lactulose 15ml TID for 10days.

6.LuLitin cream l/a OD 2 weeks .

7.ebernet plus  cream  l/a OD 2 weeks.

8.Tab Teczine 10mg SOS.

9.absorb dusting powder thrice daily.

Patient was on regular follow up since then.

10days back he had shortness of breath and pedal edema and came to OPD for follow up and is on conservative management.

3days back- patient had   h/o fever ,low grade ,relieved after taking medication (dolo 650mg ) not a/w cold/cough/vomiting /loose stools /pain abdomen /headache.

Increased drowsiness and involuntary movements since 1 day , aggravated with movement and relieved on taking rest

Past history -

Known case of HTN since 4 years ,n/k/c/o DM,asthma ,tb, epilepsy 

h/o involuntary micturation,defeaction.

Tremors - increased with movements,absent at rest.

No h/o fall,head injury,seizure activity. 

Personal history:- 

Diet- mixed 

Appetite -narmal

Bowel and bladder movement-regular

Sleep -adequate 

Addictions- 

General examination:- 

Patient is conscious, coherent,cooperative

Moderately built,moderately nourished 

No Pallor,icterus, cyanosis, clubbing,lymphadenopathy,bilateral pedal edema  

Vitals:- 

BP- 110/80mmhg

PR -85bpm

RR-20cpm

Spo2 99% at room air 

GRBS - 107mg/dl

Temperature -99.4

Systemic examination:-

Cvs: s1,s2 heard ,no Murmurs,jvp not raised 

Rs: BAE,no added sounds ,NVBS, 

P/A: soft, distended, mild tenderness in both iliac fossa 

CNS: higher mental functions intact, no focal neurological deficit 

Provisional Diagnosis-

Decompensated liver disease with portal hypertension with hepatosplenomegaly with grade 2 esophageal varices with mild Portal hypertensive gastropathy with hepatic encephalopathy grade 1  

Investigations:-

On 28th:- 

29/4

30/4

1/5

2/5

Treatment:- 

Fluid restriction<2l/day 

Salt restriction<2g/day 

As adviced by gastroenterologist 

Tab Rifagut 550 mg po/od 

Syp Hepamerz 15ml po/od 

Tab lasilactone 5/25 po/od 

Syp lactulose 15ml/po/tid 

Tab Telma 20mg po/od

Tab Propranolol 10mgpo/od

Tab pan 40mg /po/od bbf

Oroalbumen powder 2 table spoons in 1 glass of water 3 times a day  

Gastroenterologist opinion:-

Psychiatry opinion:

Discharge summary:-  

Diagnosis -

Decompensated liver disease with portal hypertension with hepatosplenomegaly with grade 2 esophageal varices with mild Portal hypertensive gastropathy with hepatic encephalopathy grade 1  

Course in hospital:-

Patient was further investigated  was treated  conservatively  psychiatry opinion was taken and was psycho educated and advised alcohol abstinence.Gastroenterologist opinion was  taken and endoscopy was done.Mild PHG with 2nd grade  esophageal varices  in 2 column and was advised  regarding liver transplantion and the same was explained  to the patient an patient attenders. 

Treatment:-

Fluid restriction<2l/day 

Salt restriction<2g/day 

As adviced by gastroenterologist 

Tab Rifagut 550 mg po/od 

Syp Hepamerz 15ml po/od 

Tab lasilactone 5/25 po/od 

Syp lactulose 15ml/po/tid 

Tab Telma 20mg po/od

Tab Propranolol 10mgpo/od

Tab pan 40mg /po/od bbf