clinical case presentation on alcoholic liver disease according to SOAP format by Rajendra Keshkar ISF college of pharmacy

1. ISF College Of Pharmacy
Ghal Kalan GT Road, Moga-142001, Punjab, INDIA
( An Autonomous College U/s UGC Act 1956 )
ALCOHOLIC LIVER DISEASE
Rajendra Kumar
Roll No.- 1813772
Class- PHARM D 2nd yr
Dept. Of Pharmacy Practice
ISF COLLEGE OF PHARMACY
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2. Demographics
Ø Name : XYZ
Ø Date of admission : 11/10/2019
Ø Date of discharge : 16/10/2019
Ø Department : Gastroenterology ( GW 02)
Ø Sex : Male
Ø Age : 55 yrs
Weight : 85 kg
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3. 1. SUBJECTIVE EVIDENCES
ØChief complaints on admission
• Patient have complaints of yellowish discolaration of skin, swelling in both lower
leg.
• c/o hard stool and fatigue
• c/o abdominal distention
ØPast medical history : k/c/o Depression, Asthma
Ø Social History : Smoker ( 1-3 cigarette per day ) since 12 years
Alcoholic since 8 years ( 40 ml - 50 ml )
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4. 2.OBJECTIVE EVIDENCES
Ø Systemic Examination
Ø CNS : Conscious and oriented
Ø Per Abdomen : Distended
Ø Vital Signs
Ø BP : 130/80mmhg
Ø PR : 80 bpm
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5. Ø LABORATORY DATA
INVESTIGATION TEST VALUE NORMAL VALUE
Hb 10.2 13-18 g/dl
TLC 9700 4000-10000 cells/cu.mm
ESR 18 0-20 mm/hr
Direct bilirubin 4.2 0-0.2 mg/dl
Indirect bilirubin 4 0.3-1.0 mg/dl
SGOT 126 Upto 35 IU/L
SGPT 72 Upto 45 IU/L
PT 27 11-15.8 sec
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6. Ø Radiographic Data
Ø USG abdomen : Fatty liver with nodules surface of liver
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7. 3. ASSESSMENT
Subjective Evidences
• Yellow discoloration of skin
• Swelling in both lower leg
• Constipation and Abdominal distention
• Fatigue
• Alcoholic since 8 years
• Smoker since 12 years
Objective Evidence
• Hb↓
• Direct Bilirubin and Indirect bilirubin Serum↑
• SGOT, SGPT↑
• USG Abdomen : Fatty liver
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Based on subjective evidence & objective evidence patient is diagnosed to have
ALCOHOLIC LIVER DISEASE

8. 4. PLANNING
l To reduce liver injury due to excessive alcohol use
l To prevent progression of Disease
l To reduce symptom
l To prevent complication
l To reduce need of hospitalisation
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9. DRUG TREATMENT CHART
BRAND NAME GENERIC NAME DOSE ROUTE FREQUENCY
Inj. THIAMINE HCL Thiamine HCL (vit B1) 100mg IV OD
Inj. HEPA MERZ L-Ornithine, L-Aspartate 5mg IV BD
Inj. VIT. K Vitamin K 10mg IV BD
Tab. FLOWPENT Pentoxiphylline 400mg ORAL TDS
Tab. RIXMIN Rifaximine 400mg ORAL BD
Tab. LASIX Furosemide 40mg ORAL BD
Syp. DUPHALAC Lactulose 20ml ORAL TDS
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10. PROGRSS CHART
DAY 1 Patient admitted with complaints of yellowish discolouration of skin, swe
lling in both lower leg, abdominal distention etc. and was diagnosed with
ALCOHOLIC LIVER DISEASE
DAY 2 NO fresh complaints seen
BP : 120/80mmHg
Pulse rate :89 bpm
DAY 3 Patient improved symptomatically
Requested for Discharge
BP :120/80 mmHg
PR : 88 bpm
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11. Goal achieved
Ø Reduce liver injury due to excessive alcohol use
reduced
Ø Disease progession prevented
Ø Signs and symptoms improved
Ø Patient quality of life improved
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