34 year old male with vomiting,hiccups and cough

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CHIEF COMPLAINTS:

34 year old male patient came to OPD with complaints of vomiting,hiccups and cough since 3 days

HISTORY OF PRESENTING ILLNESS:

patient was apparently asymptomatic 3 days back then he had vomitings 10 episodes per day which is sudden in onset,non bilious,non projectile,food and water as contents.

Vomiting is present immediately after food,water and alcohol intake.After vomiting he was associated with generalized weakness for which he went to the local hospital and was under normal saline 3 days back.There is history of dark stools 3 days back lasted for 1 day, which is non blood stained.

Hiccups Since 3 days continuously and associated with mild difficulty in swallowing 

Cough- dry since 3 days not associated with fever sore throat cold.

He also gets backpain rarely when he drives for long time relives on using pain relief balms

PAST HISTORY:

Not a known case of Dm,Tb, epilepsy, asthma,HTN

Personal History 

Diet- mixed 

Appetite- decreased 

Bowel and bladder- regular 

Sleep- regular 

Addictions-alcoholic(16 yrs back he started drinking),chews betel(starting he used to take 1 packet and now he is taking 10 packets daily)

FAMILY HISTORY:

His father died due to hernia

His mother died due to kidney failure

General examination:

Patient is conscious coherent cooperative well oriented to time place and person moderately built and nourished 

Vitals:

Temperature- afebrile

RR-16cpm

PR 75bpm

BP 130/70 mm hg

Pallor,icterus, cyanosis,generalized lymphadenopathy,edema - absent

SYSTEMIC EXAMINATION:

CVS : 

On palpation ‐

• Apex beat was felt in the 5th intercostal space medial to the mid clavicular line. 

• JVP was normal 

• No precordial bulge 

• No parasternal heave

On auscultation ‐ S1, S2 heard , no murmurs 

RS :

On inspection ‐

• Chest is bilaterally symmetrical 

• Expansion of chest: Equal on both sides

• Position of trachea: Central

• No visible scars, sinuses, pulsations

On palpation : 

• Expansion of chest was equal on both sides. 

• Position of trachea: Central

• Tactile Vocal Fremitus: resonant note was felt.

On percussion: all lung areas were resonant 

On auscultation : 

• Bilateral air entry was present, normal vesicular breath sounds were heard. 

• Vocal resonance: resonant in all areas

P/A : On inspection :-

Abdomen flat 

No distension  

No engorged veins 

No visible pulsations 

No scars

Palpation-

All inspectory findings are confirmed in Palpation

No tenderness 

No guarding rigidity 

No Hepatomegaly 

No splenomegaly

Percussion- normal

Auscultation-

 Bowel sounds are heard

CNS : The patient is well oriented to time, place, person.

Higher mental functions are intact.

Cranial nerve examination :‐

All cranial nerves are intact and functioning. 

Motor System Examination :‐

• Normal bulk in upper and lower limbs

• Normal tone in upper and lower limbs

• Normal power in upper and lower limbs

• Gait is normal 

. Reflexes are normal .

Sensory System Examination :‐

Normal sensations are felt in all the dermatomes.

No cerebellar signs .

No meningeal signs.

PROVISIONAL DIAGNOSIS:

Alcoholic liver disease

Hyponatremia with hiccups

 

INVESTIGATIONS:

02/12/22

LFT

serum electrolytes

Blood urea

serum creatinine

complete blood picture:

03/12/22

LFT

serum electrolytes

Blood urea

serum creatinine:

complete blood picture:

04/12/22

LFT

serum electrolytes:

Blood urea:

complete blood picture:

ECG:

USG:

Impression: fatty liver with mild hepatomegaly

6/12/22

Serum electrolytes:

serum creatinine:

LFT:

Blood urea:

TREATMENT:

1. IVF- 0.9 NS @ 100 ml/hr

RL- @ 100 ml/hr

2. Inj. Thiamine 200 mg in 100 ml NS IV/TID

3. Inj. Zofer 4 mg/ IV/ TID

4. Inj. Metoclopramide 10 mg/IV/SOS

5. Syp. Lactulose 30 ml/ PO/ HS

6. Tab. Udiliv 300 mg PO/BD
7. Inj. Vit K 20 mg IV/STAT (100 ml NS) followed by Inj. Vit K 10 mg in 100 ml NS/IV/BD

8. Syp. Mucaine gel 15 ml/PO/TID

9. Tab. PAN-D (40/30) PO/OD

10. Watch for any bleeding manifestations

11. Watch for signs of Hepatic encephalopathy

12. Strict I/O charting

13. Monitor vitals BP, PR, Temp

14. Inform SOS