Australian Doctor Australian Doctor 2 June 2017 | Page 14

A big drinker with visual disturbance THE AUTHOR Grand Rounds HEPATOLOGY Alcohol dependence, obesity and impaired glucose tolerance make a toxic cocktail for this patient. Dr Penny Gosling is a GP registrar in Canberra and Jerrabomberra, ACT. M ARK, 52, presented with concerns over several months of visual distur- bance. He described a distortion of vision not cleared by blinking. Past medical history Mark’s past history included obesity, obstructive sleep apnoea, impaired glucose tolerance, hyper- cholesterolaemia and known alcohol dependence. He was under the care of a psychologist to help reduce his alcohol intake. Baseline gamma-glutamyltransferase (GGT) was around 600 (RR: 5-50) and he had previously been counselled on the risk of liver damage. Mark lived with his supportive family and young children, and functioned at a high level in employ- ment. Assessment HAVE AN INTERESTING CLINICAL CASE? Email the editor at [email protected]. We pay $400 for each case and photos are encouraged. Initial assessment revealed marked new scle- ral icterus and jaundice. There appeared to be a marginal left proptosis. Visual acuity was 6/16 uncorrected. Mark had never previously required corrective lenses. Further systemic examination revealed relative haemodynamic stability. Heart rate was 96, res- piratory rate 18 and BP 122/77 (marginally lower than baseline). There was a fine tremor and when specifically elicited, hepatic asterixis. Abdomi- nal examination