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50 year old with alcoholic liver disease

 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.

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:-




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

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