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Date of admission: 31/10/2022
A 55 year old male, farmer by occupation came to casuality with shortness of breath, pain in abdomen on touch
Chief complaint: Shortness of breath, pain in abdomen on touch since yesterday
History of presenting illness:
Patient was shifted to this hospital due to development of shortness of breath while getting discharged from another hospital in his locality where the patient was diagnosed with jaundice.
Patient was apparently asymptomatic 1 week back when he developed high grade fever since 1week along with 7 to 8 episodes of vomiting which was bilious, non projectile in character constituting of no food content since 3 days for which the patient was taken to a near by hospital where he was diagnosed with Jaundice.
After discharging, the patient developed shortness of breath and was hypotensive in nature hence his attenders preferred to shift him to this hospital due to previous history of treatment here.
The patient also complained of diffuse abdominal pain on touch which was sudden in onset.
The patient was brought to the casuality around 9:00 pm.
History of past illness:
▪︎ Patient is a known case of rheumatoid arthritis since 10 years
▪︎Patient is a known case of chronic kidney disease since 10 years
▪︎Patient is a known case of diabetes and hypertension since 5 years for which he is on medication since then
▪︎Patient was diagnosed with pulmonary TB in 2018 and was started on ATT for 6 months after which the patient recovered.
▪︎Patient is known case of immature senile cataract since 5 years in left eye
▪︎Not a known case of Asthma/ CVD/ Epilepsy/ Thyroid disorder
Personal history:
▪︎Diet: mixed type
▪︎Appetite: decreased since 1 week
▪︎Sleep: adequate
▪︎Bowel and bladder movements: Patient complaints of passing hot temperature urine and passing of loose stools
▪︎Addictions : -
Surgery history:
▪︎Patient had undergone cataract surgery in right eye in 2017
▪︎Patient had undergone 3 surgeries due to cellulitis developed in his left lower leg as a result of diabetes and prolong usage of painkiller( steroidal composition ) between 2019 - 2021 when patient presented with similar complaints of bilious vomiting, loose stools with greenish discolouration and swelling in left lower leg back then to this hospital
Drug history:
Patient was consuming pain killer (steroid composition) for joint pain which was purchased over the counter for last 10 to12 years. Patient was asked to stop its consumption 1month back.
Family history:
▪︎His father and mother were known case of diabetes and hypertension.
▪︎His younger brother is known case of diabetes
Provisional Diagnosis:
Acute liver failure with AKI on CKD with k/c/o rheumatoid arthritis k/c/o diabetes mellitus with k/c/o left leg cellulitis with k/c/o HTN
General examination:
On Examination, the patient is conscious, coherent and cooperative
▪︎Moderate built and nourishment
▪︎Icterus and non pitting type of pedal edema present
▪︎Un even suface of nail with ridges can be seen
▪︎No signs of pallor, cyanosis, clubbing, koilonychia, lymphadenopathy
Vital signs:
•Temperature :102°F
•BP :80/50 mmhg
•Pulse:70 beats per min
•Respiratory rate:22 cycles per min
Local Examination:
•S1,S2 sounds heard
•No murmurs
RESPIRATORY :
•NVBS present
•BAE present
PER ABDOMEN:
Inspection:
•Abdomen distended
•Umbilicus normal
•No engorged veins, visible peristalsis,scars and sinuses
Palpation
•Soft and tender
•Pain in epigastric and lower abdomen( rt and left iliac, hypogastric region)
Clinical images:
Right eye
Investigations:
Treatment:
•Inj.piptaz 4.5 gm IV stat
•Inj.pan 40mg IV OD
•Temperature: 98.7°F
•BP : 120/70 mmhg
•Pulse: 99 beats per min
Investigations:
Blood culture report
Urine Culture Report
Hemogram
•Hb- 10.2 gm/dl
•TLC- 14000
•N/L- 85/6
•PCV- 30.6
•RBC- 3.92
•PLT- 3.01
LFT
•Total bilirubin- 8.69 mg/dl
•Direct bilirubin-6.11 mg/dl
•AST-47 IU
•ALT- 22 IU
•ALP- 212 IU
•TP-5.5 g/dl
•Albumin-3.21 g/dl
•Blood urea-95 mg/dl
•Creatinine-4.9 mg/dl
Treatment:
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