43 years old M, with icterus , vomitings, abdominal pain and decreased urine output
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan .
A 43 year old male , resident of huzurnagar, daily wage worker by occupation,came to medicine OPD with
CHEIF COMPLAINTS -
- Vomitings since 11 days
- Constipation since 11 days
- Abdominal pain since 12 days
- Decreased urine output since 12 days
Patient was apparently asymptomatic 12 days back , Then he developed abdominal pain which was sudden in onset , diffuse in nature , sharp continous , it has no aggravating factors and no relieving factors. Pain was associated with vomitings since 11 days , which is bilious and non projectile , there were 5 episodes per day . He also had difficulty in passing stools since 11 dayspassing flatus ,decreased urine output since 12 days , generalized weakness,fever which is lowgrade fever , no chills and rigors , reduced on medication
History of exposure to pet animals .
No history of rash with fever , no history of itching, no history of diarrhoea , no history of shortness of breath , palpitations, restlessness, burning micturition
PAST HISTORY
N/k/c/o DM,HTN,ASTHMA,TB,EPILEPSY
no history of previous surgeries
PERSONAL HISTORY
Patient consumes mixed diet.
Appetite-decreased since 15 days
Sleep- adequate
ADDICTIONS
Smoking-no
Gutka and khaini since 15 years
ALCOHOL-
There is a history of chronic alcoholism
- Daily consumption of alcohol is approx 1 lit.
- Choice of alcohol is not specific , drinks anything which available for cheaper cost
- He started drinking 500 ml alcohol 20 years back , Then he got married
- Later when his wife expired due to TB , he increased his alcohol to 750 ml daily
- 4 years ago when his elder daughter died due to RTA , his alcohol consumption worsened since then.
no relevant history is available
GENERAL EXAMINATION
Patient is conscious, coherent and cooperative.
Built is malnourished
No pallor, cyanosis, clubbing , generalised lymphadenopathy, pedal edema
Icterus is present
VITALS
AFEBRILE
PR-76 bpm
RR-24cpm
SpO2-98%
GRBS-108
FEVER CHARTING
SYSTEMIC EXAMINATION
P/A :-
INSPECTION
Shape of abdomen is flattened
No flank fullness is seen
Umbilicus is inverted and skin is normal
All quadrants move with respiration
No Engorged/ dilated veins
Hernial surfaces are normal
PALPATION
no tenderness
No other organomegally
No fluid thrill
Liver span us 13 cms
Bowel sounds were reduced 7/min.
No bruit
CVS- S1 AND S2 heard and no murmurs
RS- BAE+, tracheal position is central
CNS-: HMF present and no focal neurological deficits are noticed
INVESTIGATIONS
Platelet count on the day of admission was 62000
Now 1/01 2/01 3/01
1.72 2.03 2.69
Blood group:A+ve
APTT 35sec
PT:18sec
INR:1.33
ESR:0.5mm/1st houe
LDH #469
serum amylase 134 IU/L ( on 29th dec 2022 )lipase: 742 IU/L
Serum osmolality 265.4mosm/kg
ECG
USG
2D ECHO
DIAGNOSIS
Systemic Inflammatory Response Syndrome(acute pancreatitis?) a/w Multi Organ Dysfunction Syndrome
-Acute liver injury ( ALCOHOL INDUCED )
TREATMENT
TREATMENT:-
Inj. MEROPENEM 500mg iv/BD
Inj. DOXY 100mg iv/BD
Inj. PAN. 40mg iv/OD
Inj.OPTINEURON 1amp in 100ml NS iv/OD
Tab.DOLO 650mg PO/BD
Tab. VIBOLIV 500mg PO/BD
SYP. HEPAMERZ 10ml TID
SYP. LACTULOSE 15ml BD
SYP.POTKLOR 15ml PO/BD
Inj. THIAMINE 200mg in 100ml NS
Strict I/O charting
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