59-year-old Indian man, alert and conscious, cooperative, comfortably lying in supine position. He had Dupuytren's contracture, scleral jaundice and pedal edema.
On abdomen examination, there were presence of spider naevi, gynaecomastia, ascites and hepatomegaly. No other stigmata of CLD noted.
1. Provisional diagnosis?
Chronic Liver Disease
2. Possible causes of CLD?
- Viral - Hepatitis B or C, CMV, EBV
- Toxic - Alcoholic, Drug-induced eg. methotrexate
- Metabolic - Non-alcoholic fatty liver disease, Wilson's disease, haemochromatosis
- Autoimmune - Primary Biliary Cirrhosis, Primary Sclerosing Cholangitis
- Others - Right heart failure
3. Complications? Remember HEPATIK
- HEpatic encephalopathy
- Portal hypertension (variceal and rectal bleeding)
- Tumor (hepatoma)
- Infection (spontaneous bacterial peritonitis)
- Kidney failure (hepatorenal syndrome)
LFT, PT/APTT, AFP, Viral serology, Liver US, Abdominocentesis, OGDS, CXR
- Give diuretic for symptomatic relief
- Reduce risk of portal hypertension by giving beta-blocker
- Prevention of hepatic encephalopathy
Patient with right homonymous hemianopia.
How do you test patient's eyes?
Cranial nerve 2 (optic)
- Visual acuity using Snellen chart
- Colour vision using Ishihara plates
- Visual field
- Pupillary reflex
Cranial nerve 3, 4, 6 (oculomotor, trochlear, abducens)
- Eye movements - H Test
Complete examination of cranial nerves at this website.