35M came with c/o yellowish discoloration of eyes

35 year old gentlemen resident of nakrekal and works in movie theater since 1997 came with c/o yellowish discoloration of eyes since 15 days and bilateral flank pain since 14 days. 

His life style: 
patient used to wake up around 7 am and works at home such as cooking food, washing dishes and helps her mother with her daily chores. His mother had h/o fall and had history of trauma to lower back since then she is unable to do her work and used to do very minimal activity such as taking bath and going washroom and he will go to work around 10:30am after having food which consists of rice and curries which he cooked and at work he used to collect parking tickets and issuing movie tickets and works in canteen and return to home around 4:30 pm for lunch and return to theatre by 6:15pm and returns to home by 1am and dinner he may consume or not. 

In 2001 , his father met with accident and expired. And since then he is only one with his mother where as his elder sister used to live seperately with her husband and recently in 2015 she was expired due to ? Malignancy and elder brother works in rice mill. 

In 2010 , due to peer pressure he started drinking alchol occasionally once in 2-3 which gradually progressed to daily of 180ml and in 2014 he developed similar complaints with bilirubin of approximately around 16mg/dl gradually resolved after admission with in 2-3 days and later discharged( no documentation availble) and for approximately 2 years he was abstinent from alcohol and again due to their cousins he started to consume slowly and again it became his regular activity with 180-360ml/day.

Since 15 days, patient came with complaints of yellowish discoloration of eyes and he went to govt hospital and tested bilirubin was around 2-3 mg/dl and he was sent home with some medications. On 9th of this month jis mother was expired due to old age and since then again he started to consume more amount of alcohol 360ml/day . 

He went to local hospital as his yellowish discoloration was worsened and found to be having bilirubin of around 16 mg/dl and later referred to our hospital for further management. 
His right hypochondriac pain started and it is squeezing type, radiating to back with no aggravating and relieving factors, tender on palpation. 
No c/o fever, cold, cough. 
No c/o sob , orthopnea, PND. 
No c/o chest pain, palpitations, syncopal attacks . 
C/o burning micturtion since one week. 
No c/o hematemesis, melena, distension of abdomen. 

On examination, 
Patient complaiming right hypochondriac pain which is radiating to back, dragging type, no aggravating and relieving factors. 
Severe tenderness noted in right hypochondriac region. 
Liver span 19 cms
INSPECTION:
Shape scaphoid, flat, mild distension noted
Flanks free
Umbilicus Position, Shape- inverted
No Skin stretched, shiny, scars, sinuses, striae, nodules, scratch marks, puncture marks
No Dilated veins 
Normal Movements of the abdominal wall, 
No visible gastric peristalsis,
No visible intestinal peristalsis
Hernial Orifices, cough impulse negative
External genitalia Normal

PALPATION:

Superficial Palpation Tenderness, Warmth, Direction of Blood Flow in Veins

Deep Palpation
Liver
Tender non-pulsatile, no swelling noted
Right hypochondrium pain
Which moves with respiration and is
Soft in consistency with a irregular surface
And rounded edge 

Spleen - Not palpable
Hernial Orifices - Normal
No Murphys Punch/Renal angle tenderness
External Genitalia Normal

PERCUSSION:
No Fluid Thrill/Shifting dullness/Puddles sign
Percussion of Liver for Liver Span -19cms
Nixons method, Castells method, Barkuns method of percussion of the Traubes space 


AUSCULTATION:
Bowel sounds 10 to 15/min for small bowel, 3 to 5/min for large bowel
No Bruit Aortic, Hepatic, Renal Bruit
No Venous Hum

Provisional diagnosis : 
Alcholic liver disease 

Lab: 
Hemoglobin - 9.9 gm/dl
TLC - 12700 cells/cumm
N/L/E/M/B - 77/16/01/06/00
PCV - 28.5VOL%
MCV - 98.6 FL
PLATELETS - 1.6 LAKHS 
IMPRESSION - NORMOCYTIC NORMOCHROMIC ANEMIA 

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