- The patient, a 43-year-old male, presented with altered sensorium since the previous evening. - He has a history of end-stage liver disease and portal hypertension with recurrent hepatic encephalopathy. - On examination, he appeared drowsy and irritable. Investigations confirmed hepatic encephalopathy. - He was diagnosed with hepatic encephalopathy due to alcoholism and prescribed medications including cefotaxime, pantoprazole, ondansetron, lactulose, ursodeoxycholic acid, rifaximin, and L-ornithine-L-aspartic acid to treat the condition and its symptoms.

1. CASE PRESENTATION BY
RAHMAN KHAN

2. DEMOGRAPHIC
DETAILS
• NAME : Prabhu patil
• AGE : 43 yrs GENDER : male
• DOA : 15/11/2016 DOD : 16/11/2016
• DEPARTMENT : GEN MEDICINE I.P NO-532852
• UNIT A WARD: MICU

3. SUBJECTIVE EVIDENCE
PRESENT COMPLAINTS: Altered sensorium since 6 pm yesterday.
HISTORY OF PRESENT ILLNESS: Patient presented with history of
altered sensorium since 6 pm yesterday when he went to sleep
after that the patient was tired waking up at around 8:30 pm
and was not aurousable.
h/o of irrilevent talks, h/o nausea in afternoon.
No h/o fever , cough , breathlessness .

4. PAST HISTORY : patient is k/o/c end stage liver disease.
Decompensated with portal hypertension hepatic encephalopathy .
h/o recurrent addmition for the same and last admission was 2
months back. N/K/C of type 2 diabetes mellitus and hypertension. c/o
blurring of vision.
FAMILY HISTORY: nothing significant
PERSONAL HISTORY: DIET: Veg. APPETITE: Normal. SLEEP:
Undisturbed
BOWEL & BLSDDER: Normal.
HABITS: Known alcoholic scince 20 yrs last consumption 1 year back .
Non smoker.

5. OBJECTIVE EVIDENCE
PHYSICAL EXAMINATION:-
Pulse rate : 68/min .
BP : 100/60 mmHg.
Respiratory rate : 20/min .
• GENERAL EXAMINATION :-
• CVS : precordium – normal , apical impulse- 5th ICS , S1 S2 +ve
RESPIRATORY SYSTEM : B/L conducted sound +ve , trachea appears to
be central and AE B/C +ve.
ABDOMINAL EXAMINATION : Abdomen appears to be soft Non
tenderness, mild hepatomegaly +ve, bowel sound +ve.
CNS : patient appears to be drowsy and irritable , pupils B/L 5mm
rective.
PROVISIONAL DIAGNOSIS: Hepatic encephalopathy

6. INVESTIGATIONS
HEMOGLOBIN : 8 g/dl
RANDOM BLOOD SUGAR : 137 m
total count : 3800 cells/cumm
•SGPT :- 44 u/l
•SGOT:- 81 u/l
•UREA :- 42mg/dl
•CREATININE :- 1.5 mg/ml
•CHLORINE :- 108 mmol/L
•POTASSIUM :- 5.9 mmol/L
•Uric acid :- 5.7 mmol/L
•Sodium :-131 mEq/L

7. URINE TESTS : -
PUS CELLS : 2-3
EPITHELIAL CELLS : 2 – 3
SUGAR : Nil
FINAL DIAGNOSIS :-
HEPATIC ENCPHALOPATHY DUE TO ALCOHOLISM

8. DRUGS DAY 1
INJ Taxim 2gm IV (BD) √
INJ Pantop 40 mg IV √
INJ Emset 4 mg IV (sos) √
SYP Duphalac 30 ml (TD) √
TAB Udiliv 300mg (TD) √
TAB Rcifax 550 mg (BD) √
INJ Hepamerz 4 amp √
TREATMENT

9.  INJ TAXIM (cefotaxime)
MOA:- third generation cephalosporin antibiotic, active against
gram positive and gram negative bacterias by inhibiting bacterial
cell wall synthesis.
ADVERSE EFFECTS: pain and inflammation at the site of action,
rash, pruritus, or fever, colitis.
 INJ PANTOP (Pantaprazole)
MOA:- proton pump inhibitor inhibits the gastric acid secretion.
ADVERSE EFFECT: abdominal pain, nausea , dizziness etc
 INJ EMESET(ondansetron)-
MOA- It is given to reduce vomiting by blocking emetogenic
impulses in the gut and their central rely.
ADVERSE EFFECTS- Headache, dizziness, diarrhoea

10.  SYP Duphalac (lactulose)
MOA: it is a disaccharide normaly present in milk, it causes
retention of water through osmosis and has a secondary leaxitive
effect in colon.
ADVERSE EFFECT : Abdominal cramps , borborygmus and
Flatulence.
 TAB Udiliv (Ursodesoxycholic acid)
MOA: these drug reduse cholesterol absorbtion and also relive
itching in intrahepatic cholestasis.
ADVERSE EFFECT: constipation, headache, back pain, dizziness
etc.
 TAB Rcifax (Rifaximin)
MOA: it is a semisynthetic antibiotic interferes with the
transcription process of bacterial RNA
ADVERSE EFFECT: black stool, muscle spasm, troule sleeping etc.
 INJ Hepa merz(L-ornithine-L-Aspartate and pancreatin)
MOA: used in treatment of digestion of food , hepatic
ensephalopathy, treating high ammonia level,
ADVERSE EFFECT: stomach pain, vomiting bloating.

11. INJ TAXIM 2gm IV
INJ PANTOP 40mg IV
INJ EMSET 4 mg IV
SYP DUPHALAC 30 ml
TAB UDILIV 300 mg
TAB RCIFAX 550 mg

12. PLANNING
DRUG INTERACTION : ondansetron can cause an irregular heart
rhythm that may be serious and potentially life- threatening,
although it is a relatively rare side effect. The risk is increased if you
have low blood levels of magnesium or potassium, which can occur
with bowel cleansing preparations or excessive use of medications
that have a laxative effect.
COMMUNICATION WITH PATIENT :
Patient has to be explained the usage of drug and other possible
adverse effects that may occur during the therapy.
Patient should eat less protein diet.
Patient should avoid drinking alcohol.

13. THANK
YOU