A 43 year old male with icterus and decreased urinary output.

Jan 2,2023

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 complaints of
 
1) Abdominal pain since 7 days
2) Decreased urine output since 7 days
3) Vomiting since 6 days 
4) Constipation since 6 days

HISTORY OF PRESENTING ILLNESS:-

Patient was apparently asymptomatic 7 days back then developed abdominal pain which was sudden in onset,diffuse in nature, sharp and continous with no aggravating and relieving factors and associated with vomiting (4 episodes) which are non projectile and greenish in color 
He also hasn't passed stools since 6 days and complained about decreased urine output since 7 days.

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 :- adequate 
Smoking:- no
Gutka and khaini :- since 15 years
Alcohol :- 
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 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
No pallor,cyanosis, clubbing, generalised lymphadenopathy,pedal edema
     Icterus is present 
    
.     No clubbing

VITALS:-
Afebrile
PR-78bpm
RR-22cpm
BP-100/60mm Hg
SpO2-98%
GRBS-108
Fever charting:
SYSTEMIC EXAMINATION:- 
P/A :-
- shape of abdomen is scaphoid 
  No flank fullness is seen 
  Umbilicus is inverted and skin is normal 
  No engorged/dilated veins 
  Hernial surfaces are normal
-On palpation
 No tenderness
 No other organomegaly.
-No fluid thrill
 Liver span-15cm
-bowel sounds were reduced (7/min )
CVS :- S1 S2 heard and no murmurs heard 
RS :- BAE+ , NVBS heard, tracheal position is 
central 
CNS :- HMF present and no focal  neurological deficits are noticed.

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 134 IU/L ( on 29th dec 2022 )
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 )
 -Acute kidney injury
 -Dilated Cardio Myopathy ( SIRS/ ALCOHOL         INDUCED)
 -Hyponatremia and hypokalemia(resolved)


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
VITALS monitoring 6th hourly
Temperature monitoring 4th hrly

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