CASE OF A 35 YEAR OLD MALE WITH ACUTE PANCREATITIS 2° TO ALCOHOL INTAKE, RENAL/PRERENAL AKI WITH ALCOHOLIC HEPATITIS

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   I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a  diagnosis and treatment plan.

CASE PRESENTATION :

This is a case of a 35 year old male, electrician by occupation came to the OPD on 4/11/21 with:

CHIEF COMPLAINTS 

• Shortness of breath since morning
• Pain abdomen since 3-4days)
• Chest pain ( left sided) since 4 days 
• Decreased urine output since 2 days
• Hematuria since morning
•  Vomitings  since morning

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 3 days back, then he developed shortness of breath (grade III - grade IV) 

H/O binge drinking of alcohol since 10days without eating food.

Patient has pain abdomen which was stabbing type (diffuse type), non-radiating , not relieved on sitting or taking medication

It was associated with vomitings 10-12 episodes per day ( food particles as content ) bilious and non projectile. 

C/O left sided chest pain not associated with sweating ,palpitations, orthopnea , PND

C/o hematuria since morning

C/o decreased urine output since 2 days. 

No H/O burning micturition. 

Patient has passed flatus and stools. 

He visited RMP 3 days back I/v/o generalized weakness and vomitings. 

PAST HISTORY :

Not a K/C/O DM, HTN, asthma, TB, epilepsy. 

FAMILY HISTORY: Insignificant

PERSONAL HISTORY :

Diet : Mixed

Appetite: Normal

Sleep : Disturbed sleep

Bowel and Bladder habits: Decreased urine output with hematuria. 

Addictions:

Consumption of alcohol since 20 years (100ml/day) 

GENERAL EXAMINATION:

Patient is conscious, irritable, talking irrelevantly. 

He is disoriented to time. 

No signs of pallor,cyanosis,clubbing, lymphadenopathy,edema.

Icterus ++

VITALS : 

Temperature : 98.5 °F

Pulse rate : 112 bpm

RR: 22 cpm

BP: 120/80 mm Hg

SPO2 : 69% on RA 

99% on 10 litres O2

GRBS : 135 mg%

SYSTEMIC EXAMINATION :

CVS : S1 S2 heard, no murmurs

RS : Dyspnea + ( grade III - grade IV )

NVBS +

Per Abdomen : soft, tenderness + ( diffuse) 

              Guarding + in epigastrium, left hypochondrium, umbilical region. 

No rigidity. 

INVESTIGATIONS :

Hemogram: (7/11/21) 

Bleeding Time: 2 min

Clothing Time : 4min 30sec

APTT: 41 sec

Prothrombin Time: 24 sec

D- Dimer : 8590 ng/ml

RFT: (7/11/21) 

LFT: (7/11/21) 

Serum Calcium: 6.8mg/dl

ABG:

2D Echo Report :

USG Report :

ECG: 

PROVISIONAL DIAGNOSIS:

Acute Pancreatitis c̅ MODS c̅ Renal/Prerenal AKI c̅ alcoholic hepatitis c̅ hyperkalemia 2° to ketoacidosis (resolving) c̅ alcohol withdrawal c̅ refractory metabolic acidosis c̅ thrombocytopenia. 

TREATMENT :

NBM till further orders 

 IV fluids NS, RL @ 75 ml/hr continuously

 Inj .Tramadol IV/ BD

 Inj .Midaz 2cc / IV / sos   if restless .

 Inj .Meropenam 1gm / IV/ BD .

 Inj .Pantop 40 mg / IV/ OD

 Inj .Zofer 4 mg/ IV/SOS

 Inj .Thiamine 100 mg /IV / TID.