52 yr old male with infective endocarditis

 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT

A 52-year-old man presented to the OPD with Chief Complaints of abdominal distension from the past 7 days.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 2 years back, then he had a non healing injury to the right foot which raised a suspicion of Diabetes mellitus. Then they went to neatest medical care and diagnosed with Diabetes mellitus type 2 and was started on Tab. GLIMI M2 OD. 

2 years back he complained of Tingling in the upper limbs up to the palms, in the lower limbs up to the knee.  

15 Days back patient presented to the casualty with Abdominal Distension NOT associated with pain, No nausea, No Vomiting, No loose stools and was diagnosed with 

Alcoholic Liver Disease,

AKI secondary to UTI on CKD, secondary to ? Diabetic nephropathy,

Hepatic encephalopathy grade 2

From the past 7 Days, He Complains of Abdominal Distension.

From the past 5 days, he complains of Constipation and has not passed stools since 5 days.

He also complains of altered Sleep patterns from the past 5 Days 

He has hiccups since today morning

He also Complains of pedal edema grade 2

No history of chest pain, palpitation, burning micturition, shortness of breath, orthopnoea 

HISTORY OF PAST ILLNESS:

Not a known case of HTN, CAD, Asthma, TB, Epilepsy, Thyroid disorders.

No history of surgeries and blood transfusions in the past.

PERSONAL HISTORY -

He has been consuming alcohol for the past 20 years 150 ml daily , mixed diet, normal sleep, regular bowel and bladder. 

FAMILY HISTORY -

No history of DM, hypertension, CVA, CAD, Asthma, Thyroid disorders in the family.

GENERAL EXAMINATION -

Patient is conscious, coherent, co-operative.

There is icterus and pedal edema.

No pallor, cyanosis, clubbing, koilonychia, lymphadenopathy.

VITALS -

Temperature- Afebrile

Pulse rate- 92 bpm

Respiratory Rate- 24 cpm

BP-100/70 mmHg 

SPO2 at room air- 95%

GRBS 76 mg/dl

SYSTEMIC EXAMINATION -

CARDIOVASCULAR SYSTEM:

Inspection:

Chest wall is bilaterally symmetrical.

No precordial bulge

No visible pulsations, engorged veins, scars, sinuses

Palpation:

JVP: normal

Apex beat: felt in the left 5th intercostal space in the mid clavicular line.

Auscutation:

S1, S2 heard 

Ejection systolic murmur heard in all areas (aortic, pulmonary, tricuspid and mitral areas) radiating to carotids.

RESPIRATORY SYSTEM-

Position of trachea: central

Bilateral air entry +

Normal vesicular breath sounds - heard

No added sounds.

PER ABDOMEN:

Abdomen is distended, soft and non tender.

Bowel sounds heard.

No palpable mass or free fluid 

CENTRAL NERVOUS SYSTEM:

Patient is Conscious 

Speech: normal

No signs of Meningeal irritation

Motor & sensory system: normal

Reflexes: present

Cranial nerves: intact

INVESTIGATIONS:- 

2D echo-

Provisional Diagnosis:

Infective endocarditis ,

ALCOHOLIC LIVER DISEASE

WITH AKI

WITH ?UREMIC ENCEPHALOPATHY ? SEPTIC ENCEPHALOPATHY

WITH ULCER OVER SOLE OF RIGHT LEG

WITH HYPOALBUMINEMIA ? ALCOHOLIC LIVER DISEASE

Treatment :

1. Inj. Monocef 1gm IV/BD

2. Inj. Vancomycin 500mg IV/BD in 100ml NS over 1hr

3. Procto clysis enema

4. Inj. Pan 40 mg Iv/OD

5. Inj. Thiamine 200mg in 100ml NS /BD

6. Inj. HAI 6U S/C TID