Noon

report
5/7/54

 Case 58
. .

CC : 1
.

Present illness

6 .



clinic


2-3

Present illness

1 .





paracetamol 4
4-5
. admit X 3
.

Past history

Family history

Physical examinaBon
GA : An elderly male, fully conscious
V/S BT: 37C PR: 68 bpm
RR: 18 /min BP: 91/52 mmHg
HEENT : mild pale, mark jaundice , paroBd gl not
enlargement KF ring neg
SCLN, CLN impalpable
Heart : normal S1 S2, no murmur
Chest&Lung :spider nevi + ve,no
gynecomasBa ,tracheal in midline, no advenBous
sound

Physical examinaBon
Abdomen: no supercial vein dilate, so[, not
tender, no mass
Liver 1 FB below RCM , liver span 10 cms &
spleen dullness posiBve
ExtremiBes: no palmar erythema, no
edema ,punctated wound at rt lateral aspect of
leg
no apping tremor ,no echymosis

Problem list
Recurrent Jaundice

DDx

Viral hepatitis (HBV)

Drug & toxin
Autoimmune hepatitis
other

InvesBgaBon
30/6/54 Chol 92 ,Total protein 7.1 ,Alb.
3.2,Glb 3.9,TB 24.9,DB 20.2,ALT 796 ,AST
1269 Alk.P 127

InvesBgaBon
HBs Ag neg AnB HBc neg
AnB HBS neg AnB HCV neg

InvesBgaBon
AnB smooth m. Ab pending
ANA pending
Ig G 2580 [1541-2315]

InvesBgaBon
CBC Hb 10.8 / hct. 30.9
WBC 5,600(N65 L 18.7 M 11.5 E 4.7
MCV 80 Baso 0.1) Platelet 306,000
BUN 13.6,Cr 1
Na 137 K 3.8 HCO3 28.4 Cl 104
30/6/54 PT 15.44 ,PTT 32.48 , INR 1.48
2/7/54 PT 15.32 ,PTT 32.42 , INR 1.47
3/7/54 PT 14.32 ,PTT 32.42 , INR 1.41
4/7/54 PT 14.72 ,PTT 32.42 , INR 1.36

InvesBgaBon
3/7/54 TB 28.7,DB 24.6
4/7/54 TB 27.2,DB 23.2

Mx
F/U LFT ,INR ,hepaBc encephalopathy, liver
size