This is an online E-log entry blog to discuss and understand the clinical data analysis of a patient, to develop competency in comprehending clinical problems, and providing evidence- based inputs in order to come up with a diagnosis and effective treatment plan to the best of my ability.
Mentioned here are some learning points that I found interesting, both theoretical and practical surrounding this patient:
-Performed multiple Ryle's tube insertions in this patient
-Learnt how to calculate eGFR, and determine type of AKI in this patient
A 55 year old male presented to the casualty with chief complaints of:
Tingling and numbness in all limbs since 3 days
One episode of altered sensorium
History of Presenting Illness:
The patient initially started drinking 15 years ago when he was 40, due to peer pressure as all his friends in farming would drink too. Once his son met with an accident and broke his arm 6 years ago, the patient's drinking increased.
Started drinking heavily 10 days ago due to his tractor's back getting damaged due to misplacement of goods. He had recently bought that tractor by investing 4 lakhs in it. Unlike previous time, he did not eat much food during his binge episode.
In the past 10 days, he was drinking alcohol around 100ml per day.
Last drink on 1/4/2023.
Tingling and numbness since the evening around 8pm on 2/7/3023. He kept flailing his arms around and was fidgety.
On 3/7/23 had altered sensorium, was not speaking and was unable to recognise his son and wife. A few hours following this, the attenders took him to a local hospital. He refused to walk to the hospital.
At the local hospital, he was diagnosed with hypoglycemia (GRBS 40mg/dl) and hypotension (BP 50/?) For which he was given pressors and started on 25D. Following this, the doctors apparently asking about the patient's sensorium and it was noted that the patient was oriented to time, place ,person. Over there he was diagnosed with ALI, jaundice, with fever. For two days treatment was given, however, his condition was not improving. The patient attenders did not feel that the treatment was up to the mark in the hospital, hence, two days later, they decided to bring the patient to Narketpally.
Patient has been smoking since 15 years, 10-20 beedis per day. He started smoking due to peer pressure.
He came to our hospital on 4/7/2023 with the same complaints. When he came, he already had a Foley's insitu, and a nasogastric tube had already been inserted.
SUBSTANCE USE,PSYCHOSOCIAL HISTORY:
(ELICITED FROM PATIENT 'S SON WHO LIVES WITH HIM)
He started drinking 20 years ago due to peer pressure,as all his friends were drinking at the time.
For 1 month, he would continuously drink. Then for the next 5 months he would stop.
The main reason for doing this was because he didn't have enough money to spend on alcohol, so he would save up and spend all at once.
At the start of the month, he would drink beer. However because beer is costly, he would switch to whiskey after 7-10 days, around 100ml a day. Then towards the end he would drink Sara (alcohol extracted from jaggery) as it is the cheapest out of his options. He would drink about 10-15 satchets per day.
Between his binge drinking episodes, he would be sober for 5 months. As soon as he stopped drinking, he would have tremors for 3-4 days, but no other symptoms.
During his binge drinking episodes, he continued his daily routine as per usual. He would even drink and drive.
During his binge drinking months, earlier the attenders earlier used to provide him with proper food and water, to make sure he was well fed and well rested. However, they would often scold him for drinking so much. They never stopped giving him food and water though, because he was well behaved and was otherwise a good worker and was peaceful at home. So they would bear with him for the one month that he would drink.
The son, however, used to scold him often when he went into this state. The son stated that he was scared of the father's condition, especially because 2-3 relatives of theirs had died from complications due to alcoholism. He also stated that before this the father had no significant health complaints, and felt that the patient had ruined his own health by drinking.
In the last episode of binge drinking, which started 10 days before first admission, the patient and his wife fought.
The villagers had intervened, saying that it is the family member's responsibility to control this, and hence the wife scolded him. However, he shouted at his wife, which scared the son as the wife has both HTN and DM and shouldn't take stress.
So, for 4-5 days, the patient was not fed properly, nor did he ask for food. The attenders thought that maybe they were allowing his behaviour, by feeding him whenever he went into this state, so they stopped this time. He was also rarely drinking water. Following 5 days of this, his symptoms started.
The attender (patient's son) noted that Saida was not the patient's friend (history was noted because the patient kept referring to a person named Saida, saying he has to meet him).
Saida had taken a loan of 30,000 rupees from him and was refusing to return it. Before being admitted, the patient had gone to Saida 's house demanding money a few times.
Patient has also been smoking since 15 years, 10-20 beedis per day. He started smoking due to peer pressure.
Daily routine:
On days that the patient didn't drink :
He would awake up at 5.30am, breakfast around 9am- rice and some curry. Then he would go for work driving his tractor and would come back by 1pm to have lunch- rice and sambhar. He would go out again, usually for some tractor of field work. Then he would come back by 8pm for dinner.
On the days that he would drink, he would drink outside before coming home for dinner, freshen up and fall asleep. He often drove his tractor while drunk. Otherwise, he followed the same routine.
The attenders did not note any difference in his demeanor when he drank, he had always been a bit angry by nature and would raise his voice if needed. However, he never hit anyone and would rarely get into fights.
PAST History:
No similar complaints in the past.
He is not a known case of DM, HTN, CVA, CAD, asthma, epilepsy.
GENERAL EXAMINATION:
Patient is conscious, coherent and co-operative.
Mooderately built and moderately nourished.
Pallor - Absent
Icterus - Absent
Cyanosis - Absent
Clubbing - Absent
No lymphadenopathy
Pedal edema- Absent
Vitals :
Temperature - 100.2 ° F
Blood Pressure -Non recordable
Started NORAD 6ml/hr--->SBP 60mmHg--->with 2 NS BP 120/70mmHg at 6pm.
Pulse Rate -102 bpm
Respiratory Rate - 20 cpm
SYSTEMIC EXAMINATION:
PER ABDOMINAL EXAMINATION:
INSPECTION-
Shape of abdomen : flat
Umbilicus : inverted
All quadrants of abdomen move with respiration
No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites
PALPATION-
Abdomen soft
No local rise of temperature
No tenderness
Inspectors findings are confirmed
No organomegaly
PERCUSSION:
Resonant note heard over all quadrants
AUSCULTATION:
Bowel sounds heard
CVS EXAMINATION:
INSPECTION
The chest wall is bilaterally symmetrical
No dilated veins, scars or sinuses are seen
Apical impulse not visible
PALPATION:
Apex beat localised
AUSCULTATION:
S1 and S2 heard
Murmurs heard over tricuspid and pulmonic region
RS EXAMINATION:
INSPECTION:
Shape of chest: bilaterally symmetrical
Expansion of chest: Equal on both sides
Position of trachea: Central
No visible scars, sinuses, pulsations
PALPATION:
Inspectory findings confirmed
No tenderness, local rise of temperature
Normal expansion of chest on both sides in all areas
Position of trachea: Central
Vocal fremitus: resonant note felt
PERCUSSION:
Resonant note heard over all areas
AUSCULTATION:
BAE positive
Vocal resonance: resonant in all areas
CNS EXAMINATION:
HIGHER MENTAL FUNCTIONS-
Normal
Memory intact
E4V5M6
CRANIAL NERVES-
Normal
SENSORY EXAMINATION
No fine touch sensations present in soles
Normal sensations felt in all dermatomes
MOTOR EXAMINATION
Normal tone in upper and lower limb
Normal power in upper and lower limb
Normal gait
REFLEXES
Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited
EVALUATION:
Hemogram
Hb- 9.9
TLC- 9300
N/L/E/M- 77/13/1/9
PCV- 29.3
MCV- 83.5
MCH- 28.2
MCHC- 33.8
RDW-15.4
RBC-3.51
PLT-1.6
RBS- 136MG/DL
Blood urea- 69
Creatinine- 1.4
Na- 141
K- 3.0
Cl- 98
BGT- B positive
CUE
Albumin ++
Sugars ++++
Pus cells 4-5
Epithelial cells 2-4
RBCs NIL
LFT
TB- 1.14
DB- 0.50
AST- 86
ALT- 51
ALP- 69
TP- 5.1
ALBUMIN- 3.26
A/G- 1.77
Serum Amylase- 116
Serum lipase- 64
Spot urinary proteins- 4.0
spot urinary creatinine- 214
Ratio- 0.01
24 hours urinary protein- 40
24 hours urinary creatinine- 1.7
Ratio- 0.02
Blood C/S: No growth after 24 hours of incubation
Urine C/S: No growth
ECG:
Impression: Grade II Fatty Liver
CXR:
2D ECHO:
DIAGNOSIS:
DISTRIBUTIVE SHOCK WITH AKI (PRERENAL) WITH CHRONIC LIVER DISEASE WITH HYPOKALEMIA
K/C/O ALCOHOL WITHDRAWAL SYNDROME WITH DRY BERI BERI
UPDATED FEVER PROFILE WITH HEMOGRAM, RFT TRENDS:
Psychiatry referral from Day 1 of admission:
TREATMENT ADVISED:
IV FLUIDS NS, RL @75ML/HR
INJ NORAD D5 ACCORDING TO MAP
INJ MAGNEX FORTE IV BD
INJ PANTOP IV OD BBF
INJ THIAMINE 200MG IN 500ML NS IV BD
INJ ZOFER 4MG IV OD
INJ LORAZEPAM 2MG IV BD
SYP POTCHLOR 15ML IN 1 GLASS WATER IV TID
TAB OLANZEPINE 2.5MG PO BD
TAB CLINIDIPINE 10MG PO OD
TAB CHLORDIAZEPOXIDE 25MG PO OD
TAB PCM 650MG PO SOS
OINT. THROMBOPHOBE L/A
SOAP NOTES
DAY 2, 3:
S
Patient is conscious but irritable oriented to time , place , person .
Fever spikes +
Stools passed
O
Patient is conscious and confused. oriented to time , place , person .
Temp: 99.7F
Bp : 130/90 mmhg
PR: 85bpm
RR: 28cpm
CVS: s1s2 positive
RS: b/L air entry present,NVBS +
P/A: soft , non tender
CNS-NFAD
A
UROSEPSIS WITH DISTRIBUTIVE SHOCK (RESOLVED ) WITH ACUTE KIDNEY INJURY (PRE RENAL ) (RESOLVED )WITH CHRONIC LIVER DISEASE
K/c/o ALCOHOL WITHDRAWAL SYNDROME. WITH DRY BERI BERI?
P
IV fluids , NS , RL 75ml / hr
Inj PANTOP 40 mg IV /OD /BBF
Inj THIAMINE 200 mg in 500 ml NS IV /BD
Inj ZOFER 4mg IV/OD
INJ LORAZEPAM 2 mg IM /SOS
Ointment THROMBOPHOBE for L/A
TAB CLINIDIPINE 10 mg PO/OD
TAB OLANZIPINE 2.5 mg PO/BD
TAB CHLORDIAZEPOXIDE 25mg PO OD
SYP POTKLOR 15 ml in one glass water PO/TID
DAY 4:
S
Patient is conscious, coherent, cooperative. Oriented to time, place, person
No fever spikes
Stools passed
O
Patient is conscious, coherent, cooperative. oriented to time, place, person
Temp: 99.1F
BP : 140/90 mmhg
PR: 88bpm
RR: 20cpm
GRBS: 95mg/dl at 8am
CVS: S1, S2 heard
RS: B/L air entry present,NVBS
P/A: soft , non tender
CNS-NFAD
A
UROSEPSIS WITH DISTRIBUTIVE SHOCK (RESOLVED ) WITH ACUTE KIDNEY INJURY (PRE RENAL) (RESOLVED )WITH CHRONIC LIVER DISEASE WITH HYPOKALEMIA (RESOLVED)
K/C/O ALCOHOL WITHDRAWAL SYNDROME WITH DRY BERI BERI
P
IV fluids: NS, RL @ 75ml / hr
Inj PANTOP 40 mg IV /OD /BBF at 7am
Inj THIAMINE 200 mg in 500 ml NS IV /BD
Inj ZOFER 4mg IV/OD
INJ LORAZEPAM 4 mg IM /SOS
Ointment THROMBOPHOBE L/A
TAB CLINIDIPINE 10 mg PO/OD
TAB OLANZIPINE 2.5 mg PO/BD
TAB CHLORDIAZEPOXIDE 25mg PO/BD
INJ PCM 1GM SOS IF TEMP>101
ADVICE AT DISCHARGE:
1. TAB PANTOP 40MG IV OD BEFORE BREAKFAST FOR 5 DAYS
2. TAB THIAMINE 100MG PO BD
3. TAB CLINIDIPINE 10MG PO OD
4. COMPLETE ABSTINENCE FROM ALCOHOL
5. TAB LORAZEPAM 2MG
1-X-2 FOR 2 DAYS
X-X-2 FOR 2 DAYS
X-X-1 FOR 1 DAY
6. TAB BACLOFEN 2MG
1-X-1 FOR 5 DAYS
X-X-1 FOR 5 DAYS
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