A 42 year old male with body pains and fever

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed 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 E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment 

CASE:-

A 42 year old male, farmer by occupation, came to the OPD 9 days ago with complaints of fever, body pains, yellowish discoloration of the eyes and vomiting since the previous day.

    The patient was apparently asymptomatic 17 days ago. He then had decreased appetite for a week before he developed fever, body pains, yellowish discolouration of sclera and vomitings. He then got admitted to this hospital.

 

HISTORY OF PRESENT ILLNESS:-

 The patient has had a habit of drinking alcohol around 3 times a week since many years.

2 years ago, the patient's wife passed away, which increased the amount of drinking.

17 days ago, the patient started having a decreased appetite because of his drinking habits.

 10 days ago, the patient went to work to spray pesticides in the field as a part of his work. In the evening, the patient drank 90ml of alcohol and lost his appetite completely, associated with fullness of abdomen. He felt body pains and was found to have a fever,which was intermittent with medication. He also vomited. The vomit consisted of dal from his lunch. He didn't eat anything else that night.

The next day (9 days ago), he was taken to an RMP, who took his blood sample. It was found that his blood cell counts were low. He was then taken to another government hospital, where the doctors told him that his liver was damaged by his alcohol consumption. He was also told his kidney is not actively functioning and need for dialysis and then given glucose and referred to this hospital. He had hypochondrial pain with tenderness. He also had pruritus and fullness in his abdomen.

2-3 days after admission (7 days ago), the patient developed generalised swelling all over the body with body pains and tenderness in the hypochondrial region. He also didn't eat anything for these 2-3 days and was on fluids.

3 days ago, the patient's swelling and body pains got relieved with the medication, including the hypochondrial pain.

He underwent dialysis for 3 times in a week .

HISTORY OF PAST ILLNESS:-

Not a known case of diabetes, hypertension, CAD, CVA, asthma, tuberculosis, epilepsy

 

TREATMENT HISTORY:- 

Not significant

PERSONAL HISTORY:-

Diet: mixed

Appetite: decreased

Bowel movement: regular

Micturition: normal

Addictions: alcohol consumption around 3 times a week since many years

 

FAMILY HISTORY:-

 Not significant

 

PHYSICAL EXAMINATION:-

 General examination:-

(At the time of admission)

 The patient is conscious, coherent and cooperative.

  He is well built and moderately nourished.

Pallor - absent

absent

Icterus - present 

No cyanosis , lymphadenopathy , clubbing , pedal edema 

Patient is mildly dehydrated

Vitals:-

Temperature: 99 F

Pulse rate:100 bpm

Respiratory rate: 22 breaths/min

Blood pressure: 110/80mmHg

SPO2: 97%

GRBS: 126mg% 

SYSTEMIC EXAMINATION:-

 CVS:-

S1 and S2 sounds heard

No thrills and murmurs heard

Respiratory system:-

Position of trachea is central

Vesicular breath sounds heard

Abdomen:-

Distended, with hypochondrial tenderness

CNS:-

The patient was conscious, coherent cooperative and well-oriented to time and place.

Reflexes

INVESTIGATION 

30/09/22

DIAGNOSIS:-  

Viral pyrexia with acute kidney injury and multiple organ damage syndrome.

TREATMENT:-

- Fluid restriction < 1.5 lt / day 

    Salt restriction 2gm / day 

- Inj Pan 40mg IV /OD /BBF 

- Inj zofer 4mg IV / sos 

- Tab lasix 40mg IV / BD 

- IV Fluids 10 NS }

                    10 RL } 50ml / hr 

- Inj thiamine 200 mg in 100 ml NS IV/BD