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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 34 year old male patient lorry driver by occupation resident of chitiyala came to opd with chief complaints of Vomiting, Hiccups and Cough since 4 days
HOPI-
Patient was apparently asymptomatic 4 days back then he had vomiting 10 episodes per day which is sudden in onset,non bilious,non projectile,food and water as the contents.
Vomiting is present immediately after food,water and alcohol intake.After vomiting he was associated with generalized weakness for which he went to local hospital and was under normal saline 4 days back.
There is history of dark stools 4 days back lasted for 1 day, which is non blood stained.
Hiccups Since 4 days continuously and associated with mild difficulty in swallowing
Cough- dry since 4 days not associated with fever sore throat cold.
Similar complaints --3 months back he had vomiting and was diagnosed with jaundice
---10 years ago he met with an accident and was in coma for 2 days
Past History
Not a known case of Dm,Tb, epilepsy, asthma,HTN
No h/o previous surgery
No h/o any allergy
Personal History
Diet- mixed
Appetite- decreased
Bowel and bladder- regular
Sleep- regular
Addictions-
chronic alcoholic since 16years
Alcohol since 16 yrs daily ( minimum 2 pegs ,binge drinker) 3 months back he has stopped Consuming alcohol as he was diagnosed with jaundice, but strated drinking again 2 months ago occasionally .5-10days back he started consuming alcohol.
Increased consumption during night after dinner.
Also consume tobacco in the form of gutka ( betel quid ) . Starting he used to take 1 packets, now he is taking 10 packets daily .he started consuming gutka since 16 years approximately
After he stopped his studies
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-16cpm
PR 75bpm
BP 130/70 mm hg
Systemic examination
Abdominal examination
On inspection :-
Abdomen flat
No distension
No engorged veins
No visible pulsations
No scars
Palpation-
All inspectory findings are confirmed in Palpation
No tenderness
No guarding rigidit
No Hepatomegaly
No splenomegaly
Percussion-
Liver span 10 cm
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 with hiccups
Investigation
02/12/2022
Lft
serum electrolyte
Blood area
Serum creatinine
complete blood picture
4/12/2022
Lft
Serum electrolyte
Blood urea
Complete blood picture
ECG
Other investigation done
Ultra sound abdomen
Hepatomegaly,fatty liver seen in usg
Investigation
5/12/2022
Serum creatinine
Liver function tests
serum electrolyte
Treatment
1. IVF- 0.9 NS @ 100 ml/hr
RL- @ 100 ml/hr
2 Inj. Thiamine 200 mg in 100 ml NS IV/TIDI
3.Inj. Zofer 4 mg/ IV/ TID
4.Inj. Metoclopramide 10 mg/IV/SOS
5. Syp. Lactulose 30 ml/ PO/ HS
6.Inj. Vit K 20 mg IV/STAT (100 ml NS) followed by Inj. Vit K 10 mg in 100 ml NS/IV/BD
7. Syp. Mucaine gel 15 ml/PO/TID
8. Tab. PAN-D (40/30) PO/OD
9. Watch for any bleeding manifestations
10. Watch for signs of Hepatic encephalopathy
11. Strict I/O charting
12. Monitor vitals BP, PR, Temp
13. Inform SOS
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