34 year old male

This is an online E logbook to discuss our patients' 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 the available global online community of experts intending to solve those patients clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome. 

Name: G Sai Manogna

Roll no: 41

I've 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 a diagnosis and treatment plan.

Following is the view of my case :

CASE PRESENTATION:

A 34 year old male resident of nalgonda has come to the casualty with the chief complaints of 

• vomitings since 3 days
• Hiccups since 3 days
• Cough since 3 da09 iuyewasyds
• Loose stools since 1 day 3 days back

History of Presenting illness:

Patient was apparently asymptomatic 3 days back, had h/o vomitings: 10-15 episodes/day, sudden in onset, non bilious, non projectile, food and water as content

vomitings + immediately after intake of food & water associated with generalised weakness

Loose stools 4 episodes /day lasted for 3 days- normal in consistency, non mucoid, non blood stained, large volume not associated with pain abdomen & fever, black coloured stools associated with mild difficulty in swallowing

Hiccups since 3 days, continuous, no diurnal variation

Cough (dry) since 3 days, not associated with sore throat, fever, cold, itching

Past history:

H/o yellowish discolouration of eyes, vomitings 1 month back diagnosed as alcoholic liver disease and alcohol dependence syndrome

Last alcohol intake 4 days back followed which he had above complaints

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- Good

Bowel and bladder movements- Regular

Sleep- Adequate

Addictions- 

• Alcohol- regular intake, 90 ml/day since 20 years
• Tobacco- Chewable, 10-15/ day since 20 years

Family history:

No significant family history

No family history of Hypertension, Diabetes, TB, Asthma, Seizures

General Physical Examination:

Done after obtaining consent, in the presence of attendant with adequate exposure

Patient is conscious, coherent, cooperative

well oriented to time, place and person

well nourished and moderately built

Pallor- Absent

Icterus- Mild

Cyanosis- Absent

Clubbing- Absent

Lymphadenopathy- Absent

Edema- Absent

Vitals

Temperature- Afebrile

Blood pressure- 120/70 mm of Hg

Pulse rate- 88 bpm

Respiratory rate- 16 cpm

SpO2- 99% at room air

GRBS- 102 mg%

Systemic Examination:

Cardiovascular system:

S1 and S2 sounds are heard

No abnormal murmers

Respiratory system:

Bilateral air entry is present

Trachea is central

Normal vesicular breath sounds are heard

Dyspnoea is present

No adventitious sounds are heard

Abdominal Examination:

Shape of Abdomen is distended

Soft and non tender

Bowel sounds are heard

No palpable mass

Hernial orifices are normal

No organomegaly

Central Nervous System:

No focal neurological deficits

Provisional diagnosis

Alcoholic liver disease

with AKI

with hyponatremia (Hyposmolar) secondary to GI loss

with Alcohol dependence syndrome

with thrombocytopenia (82K)

Temperature charting

Investigations:

Day 1 (2/12/22)

Hemogram

Hb- 14.3 gm/dL

TLC- 6000 cells/cumm

PLT- 82000/cumm

CUE

Colour- Pale yellow

Appearance- Clear

ALB- ++

Sugar- Nil

Epithelial cells- 6-8

RBCs- 1-2

Crystals- Nil

BG Type

O POSITIVE

BT- 2 min

CT- 4 min

Serum lipase- 63

Serum Amylase- 153

Urine sodium- 110

Spot urine protein- 23.6

Spot urine creatinine- 130.2

Ratio- 0.18

Serum osmolality- 266

Liver function tests

TB- 2.85

DB- 0.96

AST- 593

ALT- 275

ALP- 196

TP- 6.6

ALB- 3.9

A/G- 1.32

Serum electrolytes

Na+ - 125

K+ - 4.4

Cl- - 82

Blood urea- 142

Serum creatinine- 4.1

Serology

Rapid HbsAg- Negative

Rapid HIV 1 & 2- Negative

Rapid Anti HCV antibodies- Negative

PT- 19

apTT- 38

INR- 1.4

ECG

Chest Xray PA view

2D ECHO

USG abdomen

SOAP NOTES

DAY 1:

S

Hiccups +

O

Patient is conscious, coherent, cooperative

Temp - 98.6 F

BP- 110/70 mmHg'

PR- 86 bpm

RR- 22 cpm

SPO2- 99% on RA

CVS- S1, S2 +, No murmurs heard

RS- BLAE +, No added sounds

P/A- Soft, non tender

HMF- Intact +

A

Alcoholic liver disease

Prerenal AKI

Hyponatremia secondary to GI loss

Alcohol dependence syndrome

P

Tab. Baclofen

SOAP NOTES

DAY 2:

S

Hiccups+

Day time sleepiness

Fever spikes

O

Patient is conscious, coherent, cooperative

Temp - 98.4 F

BP- 120/70 mmHg'

PR- 80 bpm

RR- 16 cpm

Icterus- Mild

SPO2- 99% on RA

CVS- S1, S2 +, No murmurs heard

RS- BLAE +, No added sounds

P/A- Soft, non tender

HMF- Intact +

A

Alcoholic liver disease

with AKI

with hyponatremia (Hyposmolar) secondary to GI loss

with Alcohol dependence syndrome

with thrombocytopenia (82K)

P

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. Watch for any bleeding manifestations

11. Watch for signs of Hepatic encephalopathy

12. Strict I/O charting

13. Monitor vitals BP, PR, Temp

14. Inform SOS