42 year old male with chief complaints of decreased urine output,abdominal pain,vomitings, constipation

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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 labour by occupation came to hospital with cheif complaints of 

Abdominal pain since 10 days 

Decreased urine output since 10 days

Vomiting since 9 days

Constipation since 9 days 

History of presenting illness:

 patient was apparently asymptomatic 10 days back then developed abdominal pain

Which is sudden in onset ,diffuse in nature , dull type, continous , with no aggrevating factor and relieving factor when he bends forward

History of vomitings which is non projectile and greenish incolor ,food as content 

History of constipation passing flatus ,decreased urine output, generalized weakness,fever which is lowgrade fever , no chills and rigors , reduced on medication

History of exposure to pet animals,other animals such as rats

No history of fever with rash , burning micturition, , melena 

No history of sob ( ruling out fluid overload state)

Past history : 

Not a known case of diabtes , hypertension , tuberculosis, epilepsy,bronchial asthma.

No history of any surgeries in the past

Family history: 

Not significant 

Personal history

Diet : mixed

Apeptite : decreased since 10 days

Sleep: adequate

Bladder: decreased urinw output

Addictions: consumes alcohol 750 ml daily

Type : whatever he finds cheap to buy

Started consumption of alcohol 20 years ago (500mldaily) then got married later after his wife expired he increased consuming alcohol 750 ml per day

His elder daughter also passed away 4 years back his alcohol consumption worsened since then

Gutkha intake since 15 years

 

 Treatment history:

no relevant treatment history is available 

General examination:

 patient is concious, coherent , coperative 

Thin built , poorly nourished(bmi of 16)

Icterus is present 

No signs of pallor , cyanosis, lymphednopathy, clubbing, pedal edema,

Icterus



Vitals:

Pulse rate :78 bpm

Blood pressure :110/60mmhg

Respiratory rate:22cpm

Temperature: afebrile

SpO2 : 98%

  

Fever chart:

Systemic examination : 

 Gastrointestinal tract :

Inspection:

Shape of abdomen: scaphoid

No flank fullness is seen

Umbilicus is inverted 

All quadrants move with respiration

Skin is normal 

No engorged veins ,sinunses, hernial oricfices normal

  

Palpation : nolocal riseof temperature,no tenderness 

No fluid thrill

 Liver span-15cm

Auscultation:

-bowel sounds were reduced (7/min ), nobruits

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.

INVESTIGATIONS:

HEMOGRAM (on 28/12/22)

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 (nv 0.9 to 1.3 mg/dL)

Serum electrolytes :

Sodium #119 (136 to 146 nv)

Potassium #2.6(nv 3.5to 5.1 ,i.e;moderate hypokalemia)

Chloride #94(nv 98 to 107)

Calcium #0.91(1.16 to 1.32)

ABG:

PH 7.31

Pco2:#18.1

Po2:100 mm hg

ECG :

Blood group:A+ve

APTT 35sec

PT:18sec

ESR:0.5mm/1st hour

LDH #469

To analyze pancreatitis:

serum amylase 134 IU/L ( on 29th dec 2022 )(no 30 to 125IU / I)

Serum lipase: 742 IU/L(Nv:10 to 140 IU/L)

(Serum lipase is more specific)

Serum osmolality:265.4mosm/kg



DIAGNOSIS:-

Systemic Inflammatory Response Syndrome(acute pancreatitis) along with Multi Organ Dysfunction Syndrome and Acute liver injury ( ALCOHOL INDUCED )

TREATMENT:-

Inj. MEROPENEM 500mg iv/BD(to prevent septic complications from acute pancreatitis)

Inj. DOXY 100mg iv/BD(for leptospirosis)

Inj. PAN. 40mg iv/OD(for stomach pain’

Inj.OPTINEURON 1amp in 100ml NS iv/OD

Tab.DOLO 650mg PO/BD(for fever)

Tab. VIBOLIV 500mg PO(to treat alcohol intoxication)

SYP. HEPAMERZ 10ml TID(for indigestion)

SYP. LACTULOSE 15ml BD(to treat constipation)

SYP.POTKLOR 15ml PO/BD(electrolyte imbalances)

Inj. THIAMINE 200mg in 100ml NS (thiamine storage is impaired in chronic alcohol abuse)

Discussion:

Alcohol intake chronically has affected both pancreas and liver in this case leading to mild hepatomegaly and acute pancreatitis (serum lipase elevated)

Based on clinical findings initially leptospirosis (Weils disease)was suspected but after performing MAT(microscopic agglutination test) it was ruled out

Main clinical features of leptospirosis are icterus,fever,nausea ,vomitings,hepatosplenomegaly,lymphadenopathy.

Discolouration of flanks : Cullen sign and grey turner sign

Hypokalemia was also observed which may have contributed to weakness and low blood pressure 

Criteria for SIRS:

Temperature <36>

Heart rate >90 bpm

RR >20 breaths per minute 

The patient as on 6/1/23 had resolved stomach pain,vomitings,weakness,constipation and his investigations supported these findings