1801006030 CASE PRESENTATION

LONG CASE

CHIEF COMPLAINTS:-

27 yr old male patient came to our hospital to seek medical advise for removal of tracheostomy tube. 

 HISTORY OF PRESENTING ILLNESS  : -

PSYCHOLOGICAL HISTORY:-

When young, patient was a good kid and enthusiastic.

When he was 6 yrs old he lost his father (who was a heavy drinker and was a daily wage labourer ).

After this event his mother become the sole bread winner of the family.

His brother left the house for further education,  during this time the patient started to make friends then he got addicted to alcohol.

He wasn't great with studies and used to roam jobless, he started coming to home later night.

He on his mother's request completed graduation and then started to look for a job, to support the family.

PAST HISTORY: -

● He had several episodes of seizures 3 months later following the electric shock. 

● Not a known case of HTN, DM , Asthma , TB 

● Tracheostomy was done.

FAMILY HISTORY:- 

● Father passed away and he was a heavy drinker

● Mother :- Not a known car of HTM, DM.

                     Mild knee pain in both lower limbs

.                    while climbing stairs

● Elder Brother :-  Healthy

● Sister :- Healthy

PERSONAL HISTORY:- 

Height :- 5'6 --> 164.67 cms

Weight :- 40 kg approx.

Appetite :- decreased 

Diet :- feeding done through Ryle's Tube

           Breakfast :- Protein powder shake

           Afternoon:- Rice and dal with water

           Snacks:- Biscuits and milk 

           Dinner :-  Rice and dal with water

Sleep -  Adequate

Bowel and Bladder movements-  regular 

ADDICTIONS : -

After his brother left for his further studies, patient got new friends and new habits with it at a young age.

● Alcohol - he started when he was around 16-17 yrs old.

                     Quantity unknown.

● Smoking - occasionally with friends.

● Tobacco chewing - Regular. Quantity is unknown.

TREATMENT HISTORY:-

Suction every 2 hourly.

Change in position every 2 hours.

Vitals monitoring every 4 hrs.

Tab RANITIDINE 150 mg PO/OD (morning before food)

T. LEVITARECITAM 500mg PO/OD (Night time)

T. SUPRA CAL [ CALCIUM CITRATE+VITAMIN K2-7+ CALCITRIOL ]PO/OD (after lunch)

GENERAL PHYSICAL EXAMINATION  :- 

Patient is in a vegetative state, uncooperative, appears thin, weak and malnourished

Pallor-absent 

Icterus-absent 

Cyanosis-absent 

Clubbing-absent 

Lymphadenopathy-absent 

Pedal edema- absent

Koilonychia- absent

VITALS:-

       Temperature- 2 pm -> 98.4°F

                                 4 pm -> 98.6°F

                                 6 pm -> 98.2°F

       Pulse rate- 2 pm -> 102 bpm

                           4 pm -> 102 bpm

                           6 pm -> 100 bpm

      Respiratory rate- 2 pm -> 26 cpm

                                      4 pm -> 26 cpm

                                      6 pm -> 18 cpm

      BP - 2 pm, 4 pm, 6 pm -> 110/80 mm Hg    

      SpO² - 2 pm , 4 pm -> 98% 

                  6 pm -> 100%

SYSTEMIC EXAMINATION:-

   

CENTRAL NERVOUS SYSTEM-

● GCS :- E4 V2 M4 At the time of examination

  

● Higher mental functions -

       vegetative state,  disoriented

       Speech, memory and intellect couldn't be assessed.

       Release Reflexes :-

                    Grasp reflex :- couldn't be performed as patient                                                   kept his fists clenched.

                    Glabellar reflex :- absent

                    Pout Reflex :-  absent

                    Palmo-mental reflex :-  couldn't be performed as                                                                 patient kept his fists                                                                         clenched.

 

● Cranial Nerve examination:-

          pupillary reflex :Direct and indirect light reflex seen

         Trigeminal:

                   Corneal and conjunctival present

                 

        Gag reflex is present 

        Tongue moments present

● Motor System :- 

                             Right                                    Left

                     UL               LL                     UL             LL

Bulk        wasted        wasted            wasted      wasted

Tone    hypertonia    normal       hypertonia    normal

Power :- 3/5                  3/5                3/5                3/5

Reflexes :- 

 Biceps, Triceps, Supinator reflexes are absent 

 Knee reflex positive in both limbs

 Ankle reflex positive in both limbs

 Plantar reflex positive in both limbs

● Sensory System :- couldn't be elicited

● Myoclonic jerks are seen regularly

● Gait:- couldn't be elicited

CARDIOVASCULAR SYSTEM :- 

S1 and S2 are heard.

No murmurs are heard

Apex beat felt at 5th ICS

RESPIRATORY SYSTEM :- 

 B/L basal crepitations are heard

ABDOMINAL SYSTEM:-

 Soft and non tender 

ENT EXAMINATION:-

Nose :- 

   External frame work is normal.

   DNS to left is noticed.

   Ryle's tube in the right nasal cavity. 

Oral cavity and Oropharynx:

   Couldnot be examined as patient is not co-operative.

Trachea:-

  Central

  Tracheostomy tube was placed 

INVESTIGATIONS:- 

X- RAY of neck :-

Chest X Ray :-

PROVISIONAL DIAGNOSIS :-

Hypoxic Ischemic Brain Injury Post CPR state 

TREATMENT PLAN:- 

After Neurology consultation , The Neurologist  suggested for Family Counselling and Palliative Therapy. 

References :-

Role of neuro rehabilitation in electrical injuries 

https://pubmed.ncbi.nlm.nih.gov/8848659/

Use of vitamin k2 7  (Menaquinone) in hypoxic brain injury 

 https://pubmed.ncbi.nlm.nih.gov/33090426/

----------------------------------------------------------------------------------------------------------------

short case

43 year old male, daily wage worker by occupation came to medicine opd with complaints of

CHIEF COMPLAINTS :- 

1) Abdominal pain since 5 days

2) Decreased urine output since 5 days

3) Vomiting since 4 days 

4) Constipation since 4days

HISTORY OF PRESENTING ILLNESS:-

Patient was absolutely alright 5 days back then developed abdominal pain which was sudden in onset,diffuse in nature, sharp and continous with no aggrevating and relieving factors and associated with vomiting (4 episodes) which are non projectile and greenish in color 

He also hasn't passed stools since 4 days and complained about decresed urine output since 5 days

There is a history of chronic alcoholism 

-- He consumes alcohol daily ( approx 750 ml )

-- type whatever he finds cheap depending on his daily earnings.

He hadn't eating properly since last 10 days all he'd take was alcohol.

PAST HISTORY:

N/k/c/o DM, HTN, ASTHMA, TB, EPILEPSY

No history of previous surgeries.

FAMILY HISTORY :

No relevant family history 

PERSONAL HISTORY:

Diet :- mixed

Appetite:- decreased since 10 days 

Sleep :- disturbed and reduced 

Smoking:- no

Gutka and khaini :- since 15 years

Alcohol :- He started consumption of alcohol twenty years ago (500ml) [ then he got married ]---> his wife expired ---> increased his alcohol consumption ( 750 ml/daily) --->his elder daughter also passed away 4 years back---> his alcohol consumption worsened since then

TREATMENT HISTORY :- 

No relevant treatment history is available

GENERAL EXAMINATION :- 

Patient is concious, coherent and cooperative 

built:- malnourished

CAGE CRITERIA:- 4

Signs of dehydration are seen 

   - sunken eyes

-increased feeling of thirst

   - dried lips and tongue

   - skin pinch test more than 3 secs 

 

 

 

GCS = 15

Pallor, , cyanosis, clubbing, lymphadenopathy are absent 

Icterus is seen

 

VITALS :- 

- Temp :- afebrile 

- BP:- 100/70 mm Hg

FEVER CHARTING

- RR :- 17 cpm

- PR :- 84 bpm

- SpO2 :- 99% on RA

SYSTEMIC EXAMINATION:- 

CVS :- S1 S2 heard and no murmurs heard 

RS :- BAE+ , NVBS , trcheal position is central

CNS :- HMF are functional and no focal neurological deficits are noticed.

P/A :- shape of abdomen is scaphoid 

No flank fullness is seen 

Umbilicus is inverted and no engorged veins 

Hernial surfaces are normal

rigid and guarding is seen.

On palpation diffuse tenderness is seen 

liver span :- 15 cm

No other organomegalies is felt.

bowel sounds were reduced [ 4/min ]

CLINICAL DIAGNOSIS :-

ALCOHOL INDUCED CHRONIC LIVER DISEASE,CHOLECYSTITIS, ACUTE PANCREATITIS, DEHYDRATION

INVESTIGATIONS :- 

HEMOGRAM 

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 #4.50.74 to (0.74 to 1.35 mg/dL)

Serum electrolytes 

Sodium #119

Potassium #2.6

Chloride #94

Calcium #0.91

ABG:

PH 7.31

Pco2:#18.1

Po2:109

Hco3:#8.9

Blood group:A+ve

APTT 35sec

PT:18sec

INR:1.33

ESR:0.5mm/1st hour

LDH #469

serum amylase 1349 IU/L ( on 29th dec 2022 )

Serum osmolality:265.4mosm/kg

Urinary electrolytes:

Sodium 169

Potassium 15

Chloride 180

ECG:-

USG ABDOMEN:-

2D-ECHO:-

BISAP SCORE - 2

DIAGNOSIS:-

Systemic Inflammatory Response Syndrome(acute pancreatitis?) a/w Multi Organ Dysfunction Syndrome

Dilated Cardio MyoPathy ( SIRS/ ALCOHOL INDUCED)

HYPONATREMIA  

HYPOKALEMIA

Acute Kidney Injury

ACUTE LIVER INJURY ( ALCOHOL INDUCED )

?LEPTOSPIROSIS

TREATMENT:-

Inj. MEROPENEM 1gm iv stat F/b 500mg iv/BD

Inj. DOXY 100mg iv/BD

Inj. PAN. 40mg iv/OD

Inj. ZOFER 4mg iv/sos

Inj. NEOMOL 1gm iv/sis (if temp>101°f) 

Inj. LASIX 40mg iv/BD

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

Tab. UDILIV 300mg BD

SYP. HEPAMERZ 10ml TID

SYP. LACTULOSE 15ml HS

Inj. THIAMINE 200mg in 100ml NS.