A 24 year old male with vomiting, sob and blood in urine

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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 diagnosis and treatment plan

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

CONSENT WAS GIVEN BY BOTH PATIENT AND ATTENDERS

A 24 year old male daily wage labourer came to the OPD with a 

 CHIEF COMPLAINTS of decreased urine output ,  vomiting since 9 days .Difficulty in swallowing and oral ulcers  since 8 days .

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 9 days back then he developed severe vomitings due to an excessive binge drinking without any consumption of food. The vomitings  were 4-5 episodes/day and were non bilious, non blood stained, non foul smelling, watery and occurred immediately after consumption of food or liquids. Also complaints of difficulty in swallowing since 8 days.

Patient developed oral ulcerations later that day. He was taken to a local hospital where medication (mouth wash and some gel for ulcers). was provided and did not get relief. 5 days ago he had complaints of shortness of breath (Grade 3) and decreased urine output with blood in the urine.And went to  a private hospital and endoscopy was advised and  blood tests were done in which  increased serum creatinine levels  and bilirubin levels were detected  and referred to our hospital  and got admitted for dialysis. 4 days ago the patient was observed to develop a white coating in the mouth and over the tongue( dermatology opinion taken).

He has no H/o fever, loose stools, pedal oedema,  pain abdomen, burning micturition, cold, cough .

PAST HISTORY:

No similar complaints in the past

No H/o HTN, diabetes, asthma, epilepsy and tuberculosis. 

PERSONAL HISTORY:

Diet: mixed. Appetite: normal

Bowel and bladder: irregular.      

Sleep: adequate.

 Addictions : alcohol  consumption since 4 yrs daily( around 180 ml) (binge drinking episode 2 days  back before onset of present symptoms ) and paan occassionally.

Allergies: none.

Family history: not significant 

GENERAL EXAMINATION:

Patient is conscious coherent and cooperative moderately built and nourished

Vitals

Temperature: afebrile. PR: 83bpm

RR: 22cpm. BP: 140/90mmHg

Pallor: absent 

Icterus: present

 

Clubbing: absent 

Lymphadenopathy: absent

Oedema : absent

SYSTEMIC EXAMINATION:

Per abdomen: soft on palpation, bowel sounds heard,    no distention present.

Respiratory system: no wheeze heard, no crepitus heard, normal vesicular breath sounds heard

CVS: S1 S2 heard, no additional murmurs

CNS: no focal neurological deficits.

INVESTIGATIONS: 

31/12/22: 

Hemogram

CUE:

Blood urea:

4/1/23:

PROVISIONAL DIAGNOSIS :

 Alcohol liver disease ,Acute kidney injury, aspiration pneumonia, oral candidiasis. 

Treatment:

- IV NS

- Inj zofer (SOS)

-Inj Doxycycline 100mg BD

- Inj Thiamine 200mg in 100ml NS TID

- Inj Monolef BD

- Inj Lasix 40mg BD