Thakur shalini general medicine case presentation 3

 This is an online e-log book to discuss our patient's de-identified health data shared after taking 
HIs/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

This is a case of a 30 year old male patient lorry driver by occupation. He is a chronic alcholinic since 10years (90 - 180 ml/day) &non smoker. Patient started binge drinking past 2 months after his sister marriage. One month ago, patient only had alcolic binge intake (180 - 400ml/day) for approximate 2 months without related food intake in between. Patient even stopped going to work. Last intake was one month ago. 

Chief Complaint:

Loose stools since 1month

Fever since 20 days (low grade, chills) 

Yellowish discoloration of eyes since 20 days

Weakness,loss of appetite, SOB since 

History of present illness:

Patient complaints of loose stool 3 to 4 episodes , watery, accarnal black stools since one month. Also with pain abdomen and in umbilicus. Also associated with decreased urinary output & burning Micturation associated with fever and it is intermittent low grade & associated with chills. 

History of past illness:

Yellowish discoloration of eyes since 20 days. Fever associated with generalized weakness & loss of appetite & SOB grade 2 since 20days . 

No h/O vomiting, pedal edema, orthopnae &PND.No palpitations. 

Personal history:

Diet :Mixed.

Appetite : normal

Sleep:Adequate

Bowel &bladder movements:loose stools 

Burning Micturation. 

Addiction:

Chronic alcolic since 10 yrs. 

Treatment history :

No history of drug allergies

H/O of blood donation 3 times. 

Family History:

No history of similar complaints in the family. 

Physical Examination:

General 

Pallor

Icterus

Dehydration

No cyanosis

No lymphadenopathy

No clubbing

Blackish discoloration of hands since 1year

Tongue is dry &blakish discoloration

Knuckle Hyperpigmentation. 

Increased JVP

Vitals 

Temperature

Pulse rate 120bmp

BP 100/60mmHg

Spo2 98%

Systemic Examination:

CVS:

No thrills

Cardiac sounds S1, S2 heard 

Presence of cardiac murmers

Respiratory System:

Dysponea

No wheeze

Position of Trachea - Central

Breath sounds vesicular

Abdomen:

Shape of abdomen- scaphoid

No tendernes

No palpable mass

Normal hernial orifice

No bruits 

No free fluid

CNS:

Conscious 

Speech - Normal 

Cranial nerves, motor system, sensory system normal

Provisional Diagnosis:

Pancytopenia increased evaluation (B12 deficiency) - secondary to chronic alcoholism. 

Investigations:

Liver Function Test

Hemogram

Complete urine examination

Serum iron

Blood sugar - Random

Prothrombin time

Reticulocyte count

Liver Function Test

Stool for occult blood


Serum electrolytes (Na, k, cl) 

Treatment:
1.IVF 10NS @75ml/hr (slowIV) 
Inj optineuron 1 amp in 100ml NS  IV  OF
Inj Pan 40mg /IV /OD
Inj Zofer 4mg /IV/BD
Inj ceftriaxone 1g/IV/BD
Monitor vitals 4th hourly, GRBS 8th hourly.
Plan for 10 PRBC transfer. 

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