The patient presented with epigastric pain, edema of the lower extremities, and inversion of sleep. Medical history revealed 20 years of heavy alcohol use. Physical exam found jaundice, tender hepatomegaly, and signs of chronic liver disease. Laboratory tests showed elevated liver enzymes and bilirubin. Ultrasound showed signs of steatosis and enlarged pancreas head. The clinical diagnosis was alcoholic liver disease with hepatic insufficiency and chronic pancreatitis exacerbated by recent heavy drinking.

1. MEDICAL CASE REPORT
I.PATIENT’S ID.
1.
2.
3.
4.
Name:- Zaviyalev Oleg Vyachislavovich
Age:- 38 years (5th May 1968)
Occupation:- Guard
Home address: Street Chetaeva, House – 62, flat number 63,
Kazan
5. Date of Admission:- 4th May 2006
II.MEDICAL HISTORY
1. CC:
• Epigastric Pain: severe burning pain in left hypochondrium. Pain
has engirdling character, is more pronounced in supine position
than in sitting position. This pain becomes more intense 30-40
min. after the meal. This last for about 30 – 40 min. After fasting
patient get relief from the pain so to get relief from the pain the
patient avoid having his meal regularly.
• Edema of lower extremities: - in lower extremities mainly in the
foot and the shank region. The edema is continuous and
increases during normal physical exercise. After normal physical
exercise there is pain n both legs and patient gets some relief
from this pain during rest.
• Inversion of sleep: - patient also complaints about bad sleep.
Patient can’t sleep in night, but he completes his sleep during the
day, sleep span is about 3- 4 hours.
• Stool complaints:- patient goes to toilet for defecation 7-8 times/
day with only a feeling of defecation, without stool. Stool has a
normal color with a very low quantity.

2. • Weakness –it is also one of the complaint patients the height of
weakness is in the morning. In morning patient feels himself week
but as the day proceeds he starts feeling better. He lost his
weight about 7-8 kg during his span of disease.
Secondary complaints
o Cough – patient has a irregular cough with green colored sputum,
quantity is about 20-30ml/day
o Dyspnea – appears mainly after normal physical activity.
Exhalation dyspnea
o Urination – patient goes to the toilet for urination after every 30
min.and complaints about the abdominal pain during urination.
2. HPI:
From last 20 years patient used to drink alcohol 3 times a week.
He is alcohol abused from last 20 yrs. Every time he used to drink
for about 1 litre Vodka or spirit. In the month of March 2006 he
drunk everyday 1litre spirit, and after that he started feeling
weakness & pain in the lower extremities and epigastric pain. The
patient also lost his weight by 7 kg in a month. Patient had closed
trauma of head in the year 2001, after that the problems
regarding to sleep (inversion of sleep) occurs.
At the time of admission patient had pain in epigastric region,
weakness, edema of lower extremities. Patient was referred to
the hospital by his district physician.
3. PMH:
• In 1973 when the patient was 5 years old he caught cold n was
diagnosed was established as Bronchitis
• Hypotension was diagnosed in 1992 with blood pressure of
90/60.

3. • The patient has closed trauma of his head in 2001. From that
incidence he got the problems of inversion of sleep and bad
memory.
• Fracture of his middle phalange of his little finger in 2001.
• He doesn’t have any venereal disease.
• He has done all required immunizations.
4. FH:
Father died at the age of 27 yr old but he doesn’t know exact
reason of his death.
Mother is 57 yrs old and don’t have any problem.
He also have 1 brother who is 34 yr old healthy.
Patient doesn’t know exact data about grandparent.
5. PSH:
Born in kazan on 5th may 1968, from 1st pregnancy. At the time of
birth father was 23yr old and mother was 19yr. Breast feeded
began walking at the age of 2yr, speaking at 3yr, gone to school
at the age of 7yr he completed 10th class at the age of and did not
studied further.
Emotional atmosphere at home is stressful. He lives in 2 room
apartment, separate, comfortable with partial facilities on first floor
with his family (2 members) with mother and brother.
Clothes and footwear are hygienic and corresponding to season.
He work as guard, he works for 12hr from 8 a.m. to 8 p.m.
His feeding is full, regular and prefers non-veg dishes as
sausages, soup and meat.
He used to play football when he was child.
He spends his free time in watching football or Hockey.
He is Christian by religion.
His pubertal period had gone without any complications at 14
year. He had sexual contacts from 21 year. He is a bachelor.

4. 6. MH:
• Tobacco smoking; started smoking at the age of 16yrs, smokes 1
packet, about 20cig/day. He is smoking from last 22yrs.
• Alcohol consumption: started drinking at the age 18yrs.He use to
drink alcohol from last 20yrs. He drinks 3-4 times a week, near
about 750ml vodka or spirit.
• Don’t take any narcotics and illicit drugs.
III. PHYSICAL EXAMINATION FINDINGS:
General condition:- satisfactory, temp: - 36.6 C.
Patient’s position:- active, level of consciousness: - clear.
Face expression:- Painful expression no cyanosis of lips, cheeks,
nose and ear.
Constitutional type:- normosthenic. Height: - 168 cm, weight 54
Kg, BMI 19.36 kg/m2
No Gait and Bearing abnormalities.
Color of skin is physiologic, skin is moist and elastic and state of
hair is masculine.
No exanthema, hemorrhages, vascular changes, scars.
No digital clubbing of nails.
Thickness of cutaneous fold below scapula is 1.5 cm, edema of
lower extremities (foot & shank region).
Thyroid gland: - Is palpable & diameter of isthmus is about 1cm.
Lymph nodes are not palpable.
Muscle general development of satisfactory and there is no
tenderness on palpation. His muscle tone is regular and muscular
strength is normal.
Bones ;( examination of chest, spine, extremities & skull)
Deformity of nasal bone due to trauma in yr 2001.

5. Joints;
On examination of joints changes in joint configuration, swelling
or crepitation (crunching) during motion are not reveled.
Respiratory System:
Nasal breathing is not laboured.
Chest shape: - Flat, constitutional type: - Normosthenic.
Respiratory pattern is abdominal, respiration s regular with
respiration rate 20/min.Chest respiration motion of both sides of
chest are even, symmetric and there is no lag in motion,
additional respiratory muscle doesn’t participate in respiration.
There is no area of tenderness on thoracic on cage, thoracic cage
is elastic.
Tactile fremitus is equal on both sides of chest on upper and
lower part of back.
Percussion Data:
On comparative percussion, resonant note is heard over the all
fields above lungs.
On topographic percussion, height of apices pulmones standing
from the front: on the right-3.5 cm above clavicle, on the left-3.5
cm above clavicles; from the rear: on the level of 6 vertebra.
Krenig’s areas width: on the right-7 cm, on the left-7 cm.
Lower lung borders:
Topographic lines
Parasternal
Midclavicular
Right
VI rib
VI intercostal
Left
-
space
Anterior axillary
VII intercostal
space
Midaxillary
VII
intercostal space
VIII intercostal
VIII

6. space
intercostal space
Posterior axillary
IX intercostal
space
IX
intercostal space
Scapular
X intercostal
space
Spinous process
XI
thoracic vertebra
Para vertebral
X
intercostal space
of Spinous process
XI
thoracic vertebra
of
Defining of diaphragmatic excursion:
Topographic
lines
Right
Inspiratio
n
Midclavicula
r
Midaxillary
Scapular
3
2
Left
Expiration Sum Inspiratio
n
3
2
6
4
3
2
Expiration Sum
-
-
3
2
6
4
Auscultation Data:
Main breath sound is harsh breath sound over the lung.
No any adventitious breath sound.
On bronchophony no changes in sound transmission on both
sides.
Cardiovascular system:

7. No deformities in precordium region.
Apical impulse:- apical impulse and present at 5th intercosal space
1cm medially from left midclavacular line, area of apical impulse
is about 1.5cm, strength is strong.
Cardiac impulse:-no
Epigastric pulsation:- no
Other pulsation:-no
Any kind of thrills are not present.
Percussion Data:
Cardiac relative dullness borders:
Right: - right border is situated 1cm laterally from right sternal
edge IV intercostal space
Left: - left border is situated 1cm medially from left midclavicular
line in V intercostals space
Upper: - upper border is situated 1cm lateral from left sternal line
at the level of III rib.
Heart diameter:- 3+9=12cm
Heart configuration is normal.
Cardiac superficial dullness border:Right:-right border is situated at left sternal edge in V internal
space.
Left:-left border is situated 2.5cm medially from left midclavacular
line.
Upper:-IV rib level.
Superficial dullness diameter: - 6cm
Vascular bundle width: - 5cm
Auscultation Data:
S1 and S2 are regular and normal. At the base of heart S2 is
louder than S1
Any kind of murmurs are not present.
Heart rate:-78/min is regular.
Vessels examination;Arterial pulse is 74/min and regular. Filling is satisfactory; strain is
hard and equal on both arms.
Arterial palpation and auscultation;Femoral artery is palpable and superficially located, pulsation is
strong and filling is satisfactory. Popliteal artery deep located,
pulsation is weak filling is satisfactory. Posterior tibial artery is not
palpable.

8. BP on left arm 110/70 mmHg
BP on right arms 110/65
mmHg
Venous pulse:-venous pulse is negative, central venous pressure
is 3cm.
Gastrointestinal tract:
-Tongue is white coated and with rough appearance.
-Mucous membrane is icteric, especially hard palate and bottom
surface of tongue.
-Tonsils are not inflammated.
-There is bleeding from gums during teeth cleaning.
-No any carious tooth is present.
Abdomen shape: flat, even.
Regular respiratory motions of abdominal wall.
On percussion, tympanitic note is heard over the abdomen.
On superficial palpation there is tenderness in the Guberegritz –
Skoolsky zone and patient feel pain during palpation in this area.
No hernia, tumors, no dehiscence of abdominal muscles.
Shchetkin-Blumberg’s sign is negative.
Sigmoid colon is located in left iliac region, palpable, 3 cm in
diameter, cylindrical in shape, and smooth, elastic consistency,
painless.
Cecum is located in right iliac region, palpable, 1.5 cm in diameter
cylindrical in shape, and smooth, elastic consistency, painless.
Transverse colon, ascending colon, descending colon are not
palpable.
Using percussion, auscultopercussio, auscultoaffriction, splashing
sound methods, the lower stomach border is defined at the level
3 cm above the umbilicus.
Pancreas is not palpable but during palpation there is pain in the
Guberegritz – Skoolsky zone.
Transverse colon is not palpable.
Ascending and descending colon are not palpable.
Liver span after Kurlov
Along Midclavicular line – 15 cm
Midsternal line – 9 cm
Along left costal arch – 6 cm

9. Liver palpation:-palpable 4cm below costal arch. Lower border is
smooth and with tender edge.
Spleen area: along horizontal axis- 8cm
Along vertical axis- 6cm
Urinary system :
Kidneys, urinary bladder are not palpable. Pastenatsky’s sign is
negative.
IV. PROVISIONAL DIAGNOSIS:Main
 Alcoholic liver disease chronic hepatitis: parenchymatous
jaundice with cholestatic component;
 Hepatocellular insufficiency: Hepatic encephalopathy of combined
origin (traumatic + alcoholic), prodromal stage;
 Chronic pancreatitis, recurrent form, moderate course,
exacerbation period.
Accompanied
 Chronic bronchitis, remission stage.
V. INVESTIGATION DATA
a) Blood analysis:Leukocytes - 4.5 ×109 /l, neutrophils asegmented- 5%,
segmented – 62%, lymphocytes - 27%, monocytes - 4%,
eosinophils -2%.
b) Biochemical blood analysis:-

10. Total bilirubin- 44/8/36 m mol, ALT-55.36 m mol/lit, AST35.6 m mol/lit
Amylase-17.1 gm/lit, Urea- 4.9 m mol/lit, creatinine- 69.0
m mol/lit,
Cholesterol-5.9 m mol/lit.
Total Protein- 55.19 gm/lit.
c) Urine analysis:Leukocytes – 4-5, Bilirubinurea- + ve,
Urobilinogen- -ve, Total bilirubin- 200 m mol/lit, direct100 m mol/lit, indirect- 100 m mol/lit
d) Ultrasound:Liver; right lobe- 154 mm (with signs of stephoasis
component), Gallbladder; 40/30, duct- 5 mm, Pancreas; head35 mm body- 21 mm
VI. CLINICAL DIAGNOSIS:Main
 Alcoholic liver disease chronic hepatitis: parenchymatous
jaundice with cholestatic component;
 Hepatocellular insufficiency: Hepatic encephalopathy of combined
origin (traumatic + alcoholic), prodromal stage;
 Chronic pancreatitis, recurrent form, moderate course,
exacerbation period.
VII. PATHOGENESIS OF SYMPTOMS & SIGNS
• Severe abdominal pain:-

11. Severe abdominal pain which is derived from dilation of duct
system causing ductal and parenchymal hypertension, or from
inflammation of parenchyma causing pancreatic ischemia. Patient
have recurrent attacks of pain, elevation of serum amylase, failure to
secrete pancreatic and malabsorption of fat and fat soluble vitamins,
which results in weight loss. Due to inflammation of pancreas the
size of head of pancreas is increase, which results in activation of
pain receptors. These pain receptors give sensation of pain in
epigastric region. Because of the inflammation process pain gets
engirdling character. This pain is steady, boring and persist without
relief for many hours and usually for several days.
• Edema of lower extremities:The movement of protein (eg. Albumin, clotting factors,
lipoproteins) between hepatocytes is markedly impaired so
Hypoproteinemia develops. Plasma protein level is decrease &
because of Hypoproteinemia osmotic pressure gradually decreases
& balance between oncotic pressure gradually decreases and due to
high portal venous pressure fluid accumulates into intracellular
spaces. The reduction in plasma protein concentration results from
destruction of the liver cells thus reduced the ability of the liver to
synthesize enough protein. is also associated with large amount of
fibrous tissue in liver structure , which greatly impedes the flow of
portal blood through the liver this in turn rises capillary pressure
through the portal vascular bed which also contributes the leakage of
fluid and proteins into lower extremities and oedema develops.
• Hepatocellular insufficiency:Two physiological factors appear to be important in the genesis
of this disorder- 1) severe loss of hepatocellular function 2) shunting
of blood around the chronically diseased liver due to these two
factors. Liver metabolizes and detoxifies digestive products brought
from the intestine by portal vein. In liver disease these products
escape into systemic circulation, if portal blood bypasses
parenchymal cells or if the function of these cells impaired, the
resulting toxic effects may produce the symptoms of hepatic

12. encephalopathy. The another most important function of the liver
mainly protein metabolism is altered formation of the urea by the
liver removes ammonia from the body fluids. Large amounts of
ammonia is formed by the deamination process and additional
amounts are continually formed in the gut by bacteria and then
absorbed into blood therefore if the liver does not form urea the
plasma concentration of ammonia can rise rapidly and results in
hepatic coma. Patient exhibit a spectrum of disturbances in
consciousness ranging from behavioural abnormalities to marked
confusions.
Hepatic encephalopathy is regarded as metabolic disorder of
CNS and neuromuscular system. In this case The disorder of CNS
may due to trauma of head or due to alcohol. In most instances there
are only minor morphological changes in the brain due to which
normal sleep cycle is disturbed. Patient cant sleep during night and
sleeps during the day time. It is due to neuropsychiatric syndrome
caused by liver disease and usually associated with portal systemic
shunting of venous blood. But the exact pathology behind the
inversion of sleep is unknown.
• Hepatomegaly:During percussion we can find the enlarged liver, and on
palpation the lower liver edge can be palpated 4cm below costal
arch. The lower liver borders are depressed. On ultrasound we can
found liver enlargement. Liver enlargement is an initial change and is
most common response to alcohol ingestion. The increased liver fat
is derived from the diet, and from free fatty acid mobilized from
adipose tissue. The lipid synthesized in liver is inadequately
degraded and excreted. Fat droplets of various sizes are found in
most of the hepatocytes. Other features include hydropic change in
early stages of alcoholic liver injury and giant spherical mitochondria.
The former swollen, balloon like hepatocytes reslts from impaired
release of proteins and lipoproteins. These cells degenerate and
disintegrate. So the liver size is increase (hepatomegaly).
• Biochemical blood analysis:-

13. Total bilirubin- 44/8/36 m mol, ALT-55.36 m mol/lit, AST-35.6 m
mol/lit
Amylase-17.1 gm/lit, Urea- 4.9 m mol/lit, creatinine- 69.0 m mol/lit,
Cholesterol- 5.9 m mol/lit.
Total Protein- 55.19 gm/lit.
In biochemical blood analysis the conjugated bilirubin(44/8/36 m
mol) level is increased, it is caused either by obstruction of bile ducts
of bile ducts or by damage to hepatic cells. The rate of bilirubin
formation is normal, but formed bilirubin can not pass from blood to
intestines. While the free bilirubin still enters the liver cells and
becomes conjugated in usual way. This conjugated bilirubin is then
return to blood. Thus most of bilirubin in plasma becomes
conjugated type rather than free type. So conjugated
hyperbilirubinemia can be seen in blood analysis.
In blood analysis we also can see the decrease level of total protein
(55.19gm/lit) (hypoproteinemia). It is caused due to the impaired
movement of protein (eg. Albumin, clotting factors, lipoproteins)
between hepatocytes. The movement of these proteins markedly
impaired between hepatocytes so Hypoproteinemia develops.
We also can see the sharp increase in serum amylase (17.1 gm/lit)
and ALT (55.36 m mol/lit).
• Urinalysis:Leukocytes – 4-5, Bilirubinurea- + ve,
Urobilinogen- -ve, Total bilirubin- 200 m mol/lit, direct100 m mol/lit, indirect- 100 m mol/lit
In urinalysis increase in both conjugated (100 m mol/lit) and in
unconjugated (100 m mol/lit) biliruin level. We can also see the
urobilinogen is negative in urine. It is caused by the intrahepatic
obstruction of bile flow, so o bilirubin can not reach to intestine to be
converted into urobilinogen by bacteria. Therefore no urobilinogen is
reabsorbed into blood and none can be excreted by kidney into
urine. So the urobilinogen in urine is completely negative.
VIII. SUBSTINTIATION OF DIAGNOSIS:-

14. Diagnosis is based on:
• Complaints of patient: Shows pain in epigastric region, burning pain. This pain has
engirdling character. Patient also complaint about edema and
pain in lower extremities. Weakness is also a complaint of
patient, height of weakness is in morning. Patient can’t sleep in
night but he completes his sleep during daytime (inversion of
sleep). Patient looses his weight by 7kg in a month.
•
Past medical history & History of alcohol consumption:Patient had closed trauma of head in yr 2001, after that
complaints like inversion of sleep and bad memory had been
started. Patient is alcohol abused from last 20 years, every time
he drinks about 1 litre vodka or spirit.
• Physical finding: Tongue is white coated with rough and mucous membrane has
icteric appearance. Shows hepatomegaly (liver enlargement),
lower liver border is depressed and lower liver edge has
smooth, rubber elastic consistency, and is palpable 4cm below
costal arch. During abdominal palpation there is tenderness in
Guberegritz – Skoolsky zone, tenderness in this zone is
characterized for pancreatic body inflammation.
• Investigation data: Ultrasound shows enlargement of liver with steatosis
(hepatomegaly), signs of enlargement of pancreatic head and
constriction of gallbladder. In biochemical blood analysis direct
bilirubin is increased (conjugated hyperbilirubinemia) and there
is sharp increase in ALT (55.36 m mol/lit) and serum amylase
(17.1 gm/lit). Biochemical blood analysis also indicates
hypoproteinemia (55.19 gm/lit). Urinalysis indicates increase in
both conjugated (100 m mol/lit) and unconjugated bilirubin (100
m mol/lit) level, Urobilinogen in urine is negative.