2. Name: Mr. Gnm
Sex: Male
Age: 45 years
Weight: 60 kgs
Height : 162 cms
Date Of Admission: 29/8/18
IP no: 280152
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3. SUBJECTIVE
Chief Complaints: Yellowish discoloration of eyes and urine.
History of Present Illness: Yellowish discoloration of eyes and urine since 20
days and also abdominal distension since 15 days.
Past Medical History: No H/o hematemesis / malena. He had similar
complaints in the past and was treated symptomatically at a local hospital.
Social History: Chronic ethanolic since 20 years, last drink 2months ago.
Family History: Not significant.
Allergies: NKDA.
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4. OBJECTIVE
PHYSICAL EXAMINATION
Physical Appearance:
Height : 170cms
Weight : 60kgs
BMI: 23.8kg/m2
Vital signs:
PULSE: 90 BPM
RESPIRATORY RATE: 24 breaths/minute.
BLOOD PRESSURE: 80/60 mm of Hg.
TEMPERATURE: Afebrile.
Head to toe examination:
GIT: ICTERUS
EXT: CLUBBING
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6. DIAGNOSTIC TEST:
Upper GI Endoscopy: No varices
Ultrasound-abdomen: Hepatomegaly with normal spleen and normal portal vein
Maddrey : 32
GAHS : 7
PROVISIONAL DIAGNSOSIS:
? Severe alcoholic hepatitis
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7. PHARMACEUTICAL CARE PLAN
Subjective Evidence
• Yellowish discoloration of eyes
and urine(Icterus)
• Abdominal distension
• Clubbing
• Chronic ethanolic
FINAL DIAGNOSIS:
Severe alcoholic hepatitis
No features of chronic liver disease
Objective Evidence
• Increased Bilirubin
• Low albumin
• Elevated AST
• AST/ALT ratio >1.5(1.7)
• Highly elevated GGTP
• Ultrasound-abdomen: Hepatomegaly
• Maddrey : 32
• GAHS : 7
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8. DAY 1(29/8/18)
BP:90/60 mm of Hg(hypotension)
O/E:
Icterus
No pedal edema
Clubbing
P/A:Abdomen distended
No Ascites
Strict I/O charting
Blood and Urine culture/sensitivity shown no
growth
BP:110/60mm of Hg(optimal)
DAY 2( 30/8/18)
No fresh complaints
Pt able to eat
Vitals stable
BP:130/80 mm of Hg
DRUGS GIVEN:
NS 500 ml IV Bolus
IVF.NS@100 ml on flow
Inj.MAGNEX FORTE 1.5 gm IV BD
Inj.PANTOCID 40 mg IV BD
Inj.THIAMINE 100 mg IV OD
NOVASOURCE NUTRI HEP 2 SCOOPS PO BD
Inj.MVI 1Amp IV OD
PLAN :
Maintain mean arterial pressure >/= 65mm of Hg
Monitor vitals
High protein diet(2000k.cal)
CST
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9. DAY 3 (31/8/18)
O/E: Conscious and oriented
Patient febrile(101.3 F)
No SOB,mild cough
Maintaning good U/O
Abdominal ultrasound:
Increased echotexture of liver
Upper GI Endoscopy: No varices
Bilirubin:22mg/dL
DAY 4 (1/9/18)
C/o severe alcoholic hepatitis
No fever
O/E:Patient stable
BP:100/60 mm of Hg
DAY 5 (2/9/18)
C/o severe alcoholic hepatitis
No fresh complaints
Albumin:1.7g/dL
STOP Inj.MAGNEX FORTE 1.5gm IV BD
CST
Add
Inj.PERFALGAN 1gm IV OD(STAT)
Syp.RESWAS 10 ml PO BD(SOS)
CST
Add Inj.MAGNEX FORTE 3gm IV BD
CST
Add
Inj.ALBUMIN 20% 100 ml IV BD for 2 days
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10. DAY 6 (3/9/18)
No fever spikes
No fresh complaints
Vitals stable
Bilirubin:11mg/dL
CBC:
Hb:8.7g/dL(13-18g/dL)
PCV:24%(40%-50%)
TLC:12,900 (4,000 to 11,000 cells
/mm3)
Platelet:2.4 (1.5 to 4.5 lakh /mm3)
CST
Plan for discharge
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11. DRUG CHART
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BRAND GENERIC DOSE ROUTE FREQ. CATEGORY INDICATION
NORMAL SALINE 0.9% NACL 500 ML IV STAT ELECTROLYTE HYPOTENSION
IVF NORMAL
SALINE
0.9% NACL 100 ML/HR IV OD ELECTROLYTE HYDRATION
INJ.MAGNEX FORTE CEFAPERAZONE +
SULBACTAM
1.5 GM TO 3 GMS IV BD ANTIBIOTIC INFECTION
INJ. PANTOCID PANTOPRAZOLE 40 MG IV OD PPI ULCER
PROPHYLAXIS
NOVASOURCE
NUTRIHEP
BRANCHED CHAIN
AMINO ACIDS
2 SCOOPS PO BD NUTRITIONAL
SUPPLEMENT
NUTRITION
INJ.THIAMINE THIAMINE 100MG IV OD THIAMINE
SUPPLEMENT
NUTRITION
INJ .PERFALGAN ACETAMINOPHEN 1 GM IV STAT ANTIPYRETIC FEVER
SYP.RESWAS LEVODROPROPIZIN
E
10 ML PO SOS ANTITUSSIVE COUGH
INJ.ALBUMIN 20% ALBUMIN 100ML IV BD PLASMA
PROTEIN
HYPOALBUMIN
EMIA
12. GOALS OF THE TREATMENT
Abstinence of alcohol is essential for long-term survival.
The main goal of treatment is to reduce liver injury due to excessive
alcohol use and prevent progression of liver disease(cirrhosis)
To reduce symptoms(Icterus, Abdominal distension).
Adequate nutritional intake should be assured.
Adequate fluid resuscitation
Preservation of liver function.
To improve QOL
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13. ASSESSMENT
A 45YOM admitted to hospital with complaints of jaundice and abdominal
distension, and with outside reports of altered liver function tests and hepatomegaly.
Came here for further evaluation and workup with an idea of liver transplantation
behind their thoughts.
At arrival he was heamodynamically stable with no stigmata of liver disease
Also he was not encephalopathic and his INR was normal and diagnosed with
severe alcoholic hepatitis.
As he was not fitting into transplant criteria ,liver transplantation was deferred-the
same was explained to the family.
SEVERE ALCOHOLIC HEPATITIS
• Alcohol Abstinence is the most important therapeutic intervention for patients with
Alcoholic hepatitis.
• Patients with mild or moderate alcoholic hepatitis (i.e., defined as those with a
MDF <32, a MELD <20 or a Glasgow score <9) have a relatively low 6-month
mortality related to liver disease and do not require specific treatment.
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• IVF Normal saline 100ml/hr was given for fluid management.
• Initially Inj.MAGNEX FORTE 1.5gm was given as an antibiotic,after final
diagnosis dose was increased to 3gm,as infections are common in AH patients and
the development of bacterial infections during hospitalization is associated with
poor prognosis.
• All patients with AH should receive an adequate diet (at least 35-40 calories and 1.5
g of protein per kg of ideal body weight.So a high calorie,high protein diet was
given to the patient.
• Nutrition Therapy: The presence of significant protein calorie malnutrition is a
common finding in alcoholics, as are deficiencies in a number of vitamins and trace
minerals, including vitamin A, vitamin D, thiamine, folate, pyridoxine, and zinc.
• NOVASOURCE NUTRI HEP 2 scoops was given as a nutrition source.
• Inj.MVI 1Amp in NS was given as a vitamin supplement.
• Inj.Thiamine 100mg IV OD was given for thiamine deficiency.
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• Ulcer prophylaxis with a PPI is recommended in AH patients for which
Inj.PANTOCID 40mg was given.
HYPOTENSION
• IV Normal saline 500ml Bolus was given for managing hypotension in this
patient.
FEVER
• Inj.PERFALGAN 1gm was given to treat fever as STAT medication.
COUGH
• Syp.RESWAS 10 ml was given for cough as SOS medication.
HYPOALBUNIEMIA
• Inj.ALBUMIN 20% 100 ml was given to correct albumin levels.
He responded to the above treatment well-Bilirubin reduced to 11mg/dl,eating
well and hence planned for discharge.
16. PLAN
Monitoring parameters
• Adequate nutritional intake is essential and should be monitored several times per
week.
• Monitor Liver function test
• Ultrasound of the liver and Abdominal CT scan
• Patients should be monitored for infection (pneumonia, SBP, urinary tract infection,
bacteremia)
• Monitor Complete blood picture.
• Monitor Blood sugar levels.
• Monitor vitals.
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17. PATIENT COUNSELLING
About Disease
Alcoholic hepatitis is inflammation of the liver caused by drinking too much
alcohol over many years.
If you continue to drink alcohol, the liver will continue to be damaged. Over time,
cirrhosis will develop.
The most common symptoms of alcoholic hepatitis:
• Abdomen tenderness or pain over the liver
• Poor appetite
• Yellowing of the skin and eyes (jaundice)
• Weight loss
• Tiredness and weakness
• Fever
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About Drugs
Tab.CEFTUM 500mg 1tab to be taken twice daily orally after food for 1week given
as an antibiotic.
Cap.ZINCOVIT 1cap to be taken once daily orally for 3months given as a
mutivitamin
Tab.B75 1tab to be taken once daily orally after food for 2months given as vit B1
supplement.
Novasource Nutrihep powder 2scoops to be taken twice daily orally for a month
given for nutrition.
Cap.SOMPRAZ-D 40mg 1tab to be taken once daily orally before breakfast given
for acid peptic disease
19. LIFE STYLE MODIFICATIONS
Avoid drinking alcohol.
Take appropriate amount of protein.
Take vitamin or mineral supplements recommended by your doctor.
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