35 YEARS MALE WITH VOMITING ,GENERALISED WEAKNESS AND HICCUPS

35 years male patient with   vomiting , generalised weakness  and hiccups                              

 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. 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

Shaik sameer
Roll no 204


Chief Complaints-
35 year old male lorry driver by occupation resident of chitiyal came to opd with chief complaints of
Vomiting since 3 days 
Hiccups since 3 days
Cough since 3 days
Loose stools for 1 day 3 days back

HOPI-  patient was apparently asymptomatic 3 days back then he had vomiting which was sudden in onset, 10-15 episodes per day,non bilious,non projectile,food and water as the contents
 
Vomiting is present immediately after food water and alcohol intake which is  associated with generalised weakness for which he went to local hospital in chityala and he was under saline infusion. 

 Loose stools- 4 episodes lasted for 1 day 3 days back
Non blood stained,large volume not associated with pain abdomen and fever, black coloured stools 
 
Hiccups Since 3 days continuously, associated with mild difficulty in swallowing 
 
Cough- dry since 3 days not associated with fever sore throat cold. 

Past history:
H/o  yellow discolouration of eyes associated with vomitings 5-6 episodes per day non bilious containing food particals 3 months back for which he went to local hospital and diagnosed as jaundice and treated for it.
Not a known case of HTN, DM, TB, Asthma, Epilepsy, CAD
No h/o any previous surgeries
No known allergies

Personal History 
Diet- mixed 
Appetite- decreased 
Bowel and bladder- regular 
Sleep- regular 
Addictions- chronic alcoholic since 16years (minimum 90ml per day) ,3 months back he has stopped Consuming alcohol as he was diagnosed with jaundice, but 5-10days back he again started consuming alcohol.
Increased consumption during night after dinner 
Occasional toddy consumer 
And also consumes tobacco in the form of gutka (betel quid). At first he used to take 1 packet per day now he is taking 10 packet per day
Family history 

Not significant 
 
General physical examination-

Patient is conscious coherent cooperative well oriented to time place and person moderately built and nourished 
 
Pallor -absent
Icterus- absent
Cyanosis- absent 
Clubbing absent 
Lymphadenopathy-absent 
Edema- absent 
















Vitals 
Temperature- afebrile
RR-16/min
PR 75bpm
BP 130/70

Systemic examination-
 Abdominal examination 

On Inspection 

Abdomen flat 
No distension 
Umbilicus is central
No engorged veins 
No visible pulsations 
No scars 
Flanks are full


Palpation:

All inspectory findings are confirmed in Palpation
No tenderness 
No guarding rigidity 
No Hepatomegaly 
No splenomegaly


Percussion-

Liver span 7cm

Auscultation-

 Bowel sounds are heard

Respiratory system-

Trachea is central 
B/l air entry is present 
Normal respiratory movements 
Normal vesicular breath sounds

Cardiovascular system-
S1 and S2 heard no murmurs present 


CNS examination 
No focal neurological deficits 

Provisional diagnosis
Alcoholic liver disease
Hyponatremia 
Acute kidney injury

Investigations

02/12/2022

LFT
           
                    
 

Serum electrolytes 

                        
Blood urea 
                                           

 Serum creatinine 

                       
   
Lipase-


Serum amylase-

Urine protein/creatinine ratio

Complete blood picture


Complete urine examination 
 


03/12/2022

Complete blood picture


 Serum electrolytes


LFT


Serum creatinine


Blood urea


Prothrombin time



04/12/2022

Complete blood picture


Serum electrolytes


LFT


Blood urea


ECG


5/12/22

LFT


SERUM ELECTROLYTES

BLOOD UREA


SERUM CREATININE


COMPLETE BLOOD PICTURE






Other investigations

Chest x ray



USG abdomen



Treatment

1. IVF- 0.9 NS @ 100 ml/hr
RL- @ 100 ml/hr
2. Inj. Thiamine 200 mg in 100 ml NS IV/TID
3. Inj. Zofer 4 mg/ IV/ TID
4. Inj. Metoclopramide 10 mg/IV/SOS
5. Syp. Lactulose 30 ml/ PO/ HS
6. Tab. Udiliv 300 mg PO/BD
7. Inj. Vit K 20 mg IV/STAT (100 ml NS) followed by Inj. Vit K 10 mg in 100 ml NS/IV/BD
8. Syp. Mucaine gel 15 ml/PO/TID
9. Tab. PAN-D (40/30) PO/OD
10.Strict I/o charting











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