40 year old Male with jaundice and pruritus with type 2 diabetes mellitus

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Name:M.Srilekha(intern)

Chief complaints:

Yellowish discolouration of eyes since 20 days

Itching all over the body since 20 days 

History of presenting illness:

Patient was apparently asymptomatic 20 days back then he developed yellowish discolouration of eyes and greenish yellow discolouration of urine

Loss of appetite present

Relieved on medication which was prescribed by local RMP

Loss of weight from 52 kg to 47 kg in 20 days

Abdominal tightness present and relieved on medication 

No h/o bloating no h/o abdominal pain, constipation,

Incomplete evacuation of stools since 20 days passing pale coloured stools

No h/o fever, vomiting, diarrhoea 

No decrease in urine output

No abdominal distension

Itching all over the body present

History of usage of herbal medication usage for 6 days which aggravated yellowish discolouration and pruritus so stopped using them

Past history:

Past medical history  known case of diabetes mellitus since 4 months on Tab.Glimi-M1( METFORMIN 1000mg+GLIMIPRIDE 1mg)

Not a k/c/o HTN CVA CAD epilepsy TB

Past surgical history 

No significant past surgical history .

Personal history:

Diet mixed 

Appetite decreased relieved on medication

Sleep adequate

Bowel and bladder regular 

No known allergies

Habits:regularly takes  alcohol 90ml/day stopped 1 month back

Family history: no significant family history 

General examination:

Patient is conscious coherent cooperative 

Icterus present

No pallor cyanosis clubbing lymphadenopathy edema 

Vitals:

PR:80bpm

BP:100/60 mmHg

RR:16 cpm

Spo2:98%

GRBS:238mg/dl

CVS examination:

S1,S2 heard

No additional sounds heard

RS examination:  position of trachea central 

BAE +, NVBS +

Per abdomen:

Shape of abdomen scaphoid 

No tenderness

No palpable mass

Liver palpable:dullness on percussion at 6 th IC space ,lower border 4-5  below costal margin 

Liver span 16cpm

Investigations:

USG: no sonological abnormality 

Chest X-ray:

ECG:

2D echo:

Trivial TR, no MR/AR

No RWMA, no AS/MS

Good LV systolic function 

No diastolic dysfunction no PAH/PE

Gastroenterologist opinion was taken I/v/o alcoholic liver disease they advised MRCP

Psychiatry referral fine I/v/o alcohol consumption impression:alcohol dependence syndrome currently abstinent

Dermatologist referral I/v/o pruritus 

Diagnosis: pruritus secondary to hyperbilirubinemia

Tab. TECZINE 10 mg od/sos

Liquid paraffin/ cebhydra lotion LA/BD 

Provisional diagnosis:choleatatic jaundice with pruritus with type 2 DM

Treatment:

Day-1(16/2/23)

1.T.UDILIN 300 mg

2.syp.HEPAMERZ 10 ml po od

3.T.LEVOCET 10mg po h/s 9.00 pm

4.T.GLIMIPERIDE 1 mg po od

5.T.METFORMIN 1000mg po od after breakfast

6.pulse rate , BP , RR, temperature monitoring 4th hourly

Advice at discharge 

T.GLIMIPERIDE 1 mg po od

T.METFORMIN 1000mg po od after breakfast

T.HEPTAGON po/bd x1 week

T.BRONAC 60 mg po/ BD x1 week

Cholestyramine oral suspension po/BD x1 week

syp.HEPAMERZ 10 ml po od x 1 week