1801006030-SHORT CASE

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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.

43 year old male, daily wage worker by occupation came to medicine opd with complaints of

CHIEF COMPLAINTS :- 

1) Abdominal pain since 5 days

2) Decreased urine output since 5 days

3) Vomiting since 4 days 

4) Constipation since 4days

HISTORY OF PRESENTING ILLNESS:-

Patient was absolutely alright 5 days back then developed abdominal pain which was sudden in onset,diffuse in nature, sharp and continous with no aggrevating and relieving factors and associated with vomiting (4 episodes) which are non projectile and greenish in color 

He also hasn't passed stools since 4 days and complained about decresed urine output since 5 days

There is a history of chronic alcoholism 

-- He consumes alcohol daily ( approx 750 ml )

-- type whatever he finds cheap depending on his daily earnings.

He hadn't eating properly since last 10 days all he'd take was alcohol.

PAST HISTORY:

N/k/c/o DM, HTN, ASTHMA, TB, EPILEPSY

No history of previous surgeries.

FAMILY HISTORY :

No relevant family history 

PERSONAL HISTORY:

Diet :- mixed

Appetite:- decreased since 10 days 

Sleep :- disturbed and reduced 

Smoking:- no

Gutka and khaini :- since 15 years

Alcohol :- He started consumption of alcohol twenty years ago (500ml) [ then he got married ]---> his wife expired ---> increased his alcohol consumption ( 750 ml/daily) --->his elder daughter also passed away 4 years back---> his alcohol consumption worsened since then

TREATMENT HISTORY :- 

No relevant treatment history is available

GENERAL EXAMINATION :- 

Patient is concious, coherent and cooperative 

built:- malnourished

CAGE CRITERIA:- 4

Signs of dehydration are seen 

   - sunken eyes

-increased feeling of thirst

   - dried lips and tongue

   - skin pinch test more than 3 secs 

 

 

 

GCS = 15

Pallor, , cyanosis, clubbing, lymphadenopathy are absent 

Icterus is seen

 

VITALS :- 

- Temp :- afebrile 

- BP:- 100/70 mm Hg

FEVER CHARTING

- RR :- 17 cpm

- PR :- 84 bpm

- SpO2 :- 99% on RA

SYSTEMIC EXAMINATION:- 

CVS :- S1 S2 heard and no murmurs heard 

RS :- BAE+ , NVBS , trcheal position is central

CNS :- HMF are functional and no focal neurological deficits are noticed.

P/A :- shape of abdomen is scaphoid 

No flank fullness is seen 

Umbilicus is inverted and no engorged veins 

Hernial surfaces are normal

rigid and guarding is seen.

On palpation diffuse tenderness is seen 

liver span :- 15 cm

No other organomegalies is felt.

bowel sounds were reduced [ 4/min ]

CLINICAL DIAGNOSIS :-

ALCOHOL INDUCED CHRONIC LIVER DISEASE,CHOLECYSTITIS, ACUTE PANCREATITIS, DEHYDRATION

INVESTIGATIONS :- 

HEMOGRAM 

HB 11.4GM/DL 

TLC #23,200 

N/L/E/M/B. #85/07/#00/08/00

PCV #31.8

MCV 88.6

MCH 31.8

MCHC 35.8

RDW-CV #14.5

RDW-SD #47.7

RBC. #3.59

PLT. 62,000

CUE :- 

ALBUMIN ++

BILE SALTS AND PIGMENTS NIL

PUS CELLS NIL 

LFT :- 

Total Bilirubin #14MG/DL

Direct Bilirubin #13.20MG/DL

SGOT #94 IU/L 

SGPT #50 IU/L 

ALP. # 224 IU/L

TP # 4.9gm/dl 

albumin. #2.4gm/dl 

A/G RATIO. 0.96

RFT:

Blood urea #196 (6 to 24 mg/dL)

Serum creatinine #4.50.74 to (0.74 to 1.35 mg/dL)

Serum electrolytes 

Sodium #119

Potassium #2.6

Chloride #94

Calcium #0.91

ABG:

PH 7.31

Pco2:#18.1

Po2:109

Hco3:#8.9

Blood group:A+ve

APTT 35sec

PT:18sec

INR:1.33

ESR:0.5mm/1st hour

LDH #469

serum amylase 1349 IU/L ( on 29th dec 2022 )

Serum osmolality:265.4mosm/kg

Urinary electrolytes:

Sodium 169

Potassium 15

Chloride 180

ECG:-

USG ABDOMEN:-

2D-ECHO:-

BISAP SCORE - 2

DIAGNOSIS:-

Systemic Inflammatory Response Syndrome(acute pancreatitis?) a/w Multi Organ Dysfunction Syndrome

Dilated Cardio MyoPathy ( SIRS/ ALCOHOL INDUCED)

HYPONATREMIA ( 

HYPOKALEMIA

Acute Kidney Injury

ACUTE LIVER INJURY ( ALCOHOL INDUCED )

LEPTOSPIROSIS?

TREATMENT:-

Inj. MEROPENEM 1gm iv stat F/b 500mg iv/BD

Inj. DOXY 100mg iv/BD

Inj. PAN. 40mg iv/OD

Inj. ZOFER 4mg iv/sos

Inj. NEOMOL 1gm iv/sis (if temp>101°f) 

Inj. LASIX 40mg iv/BD

inj. OPTINEURON 1amp in 100ml NS iv/OD

Tab. UDILIV 300mg BD

SYP. HEPAMERZ 10ml TID

SYP. LACTULOSE 15ml HS

Inj. THIAMINE 200mg in 100ml NS