32 yrs old male with abdominal pain and vomitings

 THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT


This is a case of 32 yr old male resident of nagaram , housekeeper in a hospital in kachiguda came to general medicine OPD with 

CC: patient came to OPD with cheif complaints of abdominal pain , vomiting, Sob since 5 days.


HOPI : patient was apparently asymptomatic 10 days back then he developed fever without chills and rigor , with no diurnal variation , yellowish urine without burning micturition , b/l pedal edema upto ankle , facial puffiness , for which he has gone to rmp and diagnosed as jaundice, later on 24 th he took a herbal medicine, and on 25 he developed abdominal pain which is sudden in onset and gradually progressive ,  squeezing type ,no aggregating factors and relieved on walking , vomiting 2 to 3 episodes per day which is bilious , non projectile associated with abdominal pain , Sob since 5 days, insidious in onset and gradually progressive, grade 4 type .


PAST HISTORY 



 2 months back his father died and in the family gathering he started binge alcohol consumption for 2 months with little consumption of food, later he developed yellowish urine and constipation. 

Not a k/c/o hypertension, diabetes, thyroid, tb, epilepsy, asthama .


FAMILY HISTORY:  

no relavent family history.


Drug history: 

5 days back he took a dose (50 ml ) of herbal medicine


PERSONEL HISTORY: 

Daily routine

He wakes up at 5:30 am and do his morning routine, eats breakfast at 7:00 am , usually he eats idli , dosa and goes to work ( housekeeper in hospital) , lunch at 1:00 pm , after his duty he returns to his home by 7:00 pm , eats dinner at 8:00 pm goes to bed at 10: 00 pm . 

Diet : Mixed 

Appetite : adequate 

Sleep : adequate 

Bowel and bladder : regular 

Addictions - drinks alcohol since 9 years 

Gutka ( ambar ) consumption - occasionally


FAMILY HISTORY:  no relavent family history.


GENERAL EXPLANATION:

pt is conscious, coherent, cooperative and we'll oriented with time,place,person

Pallor:. No  




ICTERUS: PRESENT



Cyanosis: Absent  





Clubbing: Absent 

Lymphadenopathy: No

Pedal edema: Absent 

VITALS:

TEMP:  98.5 F 

PR: 122 bpm 

RR: 22 cpm 

BP: 110/80 

SYSTEMIC EXAMINATION:


ABDOMINAL EXAMINATION:


INSPECTION: 

Mild distension 

Scaphoid abdomen , no engorged veins , inverted umbilicus  




PALPATION: 

Tenderness in umbilicus, epigastrium, hypogastrium region 


PERCUSSION: 

dull note on right hypochondrium


AUSCULTATION: 

Bowel sounds are heard 


Cardio vascular examination:


No visible pulsations, scars, engorged veins. No rise in jvp 


Apex beat is felt at 5 Intercoastal space medial to mid clavicular line.


 S1 S2 heard . No murmurs.



Respiratory system :


Shape of chest is elliptical, b/l symmetrical.


Trachea is central. Expansion of chest is symmetrical


 Bilateral Airway Entry - positive


 Normal vesicular breath sounds


CNS examination:


 No neurological deficit found.


Gait: normal.


Normal speech.





INVESTIGATION:

1)USG:


2)HEAMOGRAM: 


3) COMPLETE URINE EXAMINATIO


4)SERUM CREATININE: 



5)BLOOD UREA




6)SERUM ELECTROLYTES and SERUM CALCIUM


7)LIVER FUNCTION TEST:  


ECG : 



Provisional diagnosis

Jaundice  , Aki  

Alcoholic hepatitis ? 

Acute liver injury? Hepatic encephalopathy? 


TREATMENT:

ON 29/11/22

1)IV RL AND IV NS(75ML/HR)

2)INJ PANTOP 40MG/IV/OD

3)TAB UDILIV 300MG/PO/BD

4) HEAD END ELEVATION UPTO 30

5)INJ THIAMINE 1amp IN 100ML NS/IV/TID

6)INJ MONOCEF 1GM/IV/BD

7)SYP LACTULOSE 10ML/PO/BD

8)I/O CHARTING 

9)TEMP CHARTING 4TH HOURLY

10)MONITOR/VITALS

ON 30/11/22

1) IVF RL AND NS(75ML/HR)

2)INJ PANTOP 40MG/IV/OD

3)INJ MONOCEF 1GM/IV/BD

4)TAB.UDILIU 300MG/PD/BD

5)TAB.ZOFER 4MG/PO/SOS

6)INJ THIAMINE 1AMP IN 100ML/NS/IV/OD

7)SVP LACTULOSE10ML/PO/BD

8)STRICT ZLOCHARANG

9)TEMP CHARANG4TH HRLY

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