18 year old male patient elog

A 18 year old male,from miryalaguda,who is a student, came to the hospital with chief complaints of low backache 1 week ago,fever since 5 days ,yellowish discolouration of eyes since 3 days ,vomitings (2 episodes) and loose stools(3 episodes)and blood tinged urine yesterday morning

HISTORY OF PRESENT ILLNESS-

Patient was apparently asymptomatic 6 months ago,then he noticed gradual loss of weight since 6months,patient had history of polyuria,nocturia,polydypsia since 2 months

10 days ago, patient attended a function outside and after 2 days he developed low backache and 2 episodes of vomitings and 3 episodes of loose stools for one day which subsided on its own.

Next day,patient developed fever,intermittent,high grade,subsided with medication. Patient went to RMP and got treated for fever.patient noticed yellowish discolouration of eyes and urine 3 days ago.Nausea and loss of appetite +

Burning micturition is present

PAST HISTORY-

No history of diabetes,asthma,TB ,epilepsy

PERSONAL HISTORY-

Diet-mixed

Appetite-lost

Bowel and bladder-regular

Sleep-adequate

FAMILY HISTORY-

No relevant family history

GENERAL EXAMINATION-

Patient is conscious,coherent and cooperative

VITALS-

Temp-

BP-110/70 mm Hg

PR-94

RR-24

Pallor- absent

Icterus-present

Cyanosis-absent

Lymphadenopathy-absent

Clubbing-absent

Oedema-absent

SYSTEMIC EXAMINATION

CVS-

S1,S2 heard

No murmurs

No thrills

RESPIRATORY-

Bilateral air entry with normal vesicular breath sounds,no wheeze,no dyspnea ,position of trachea is central

ABDOMEN-

Shape-scaphoid

Tenderness in right hypochondrium,epigastrium

No palpable mass, free fluid,no bruit

Liver and spleen- not palpable

Bowel sounds-present

PROVISIONAL DIAGNOSIS-

acute viral hepatitis

Denovo DM type 1

DKA

INVESTIGATIONS-

Update on day 5-

Subjectively-c/o lethargy from today afternoon. Did not pass urine the entire day.

Objectively- pt is drowsy not responding to verbal commands, responding to painful stimulus , giving bizarre starey looks occasionally.

BP-110/70

PR-70bpm regular normal volume

Abdomen- Palpable bladder

Assessment- ? Absence seizure / ? Intra parenchymal bleed

Plan-sr electrolytes sent

CT brain planned now

Update on day 6-

Acute liver failure with ?acute pancreatic failure

?Hepatic encephalopathy

Indirect hyperbilirubinemia-? Criggler najjar syndrome

?hepatic coagulopathy

?porphyria

Diabetic ketoacidosis (resolved)

?denovo diabetes type 1

Patient became drowsy and not responding to verbal communication since yesterday evening with acute retention of urine,bizarre starey looks, responding to painful stimuli

?absence seizure

Inj. Loraz 2cc given yesterday night

CT brain done- normal

O/E-

GCS-E2 V2 M3

Pupils-B/L RL dilated

BP -130/80 mmHg

PR-70 bpm

Temp- 100F

CVS- S1,S2 heard

RS- BAE

UPDATE ON DAY 10-

His repeat LFT

TB 14.3

Indirect bilirubin 4.6

DB 9.6

SGOT 190

SGPT 750

ALP 113

TP 6.2

*Alb 2.5*

Glb 3.7

A/G 0.6

Serum ammonia :108 (Normal range)

Urine for porphobilinogen negative

Yesterday night he had one more episode of ?absence seizure where he had loss of awareness of surroundings with staring look and repeating a single word for about 15mins

**covid antibodies positive

Update on day 13-

Update on day 15-

Update on day 17-

discharge summary-

Date:29/6/21

Ward:GENERAL MEDICINE

Unit:5

NAME OF THE TREATING FACULTY-

DR.E.SAI NIKITHA (INTERN)

DR.SRAVANI(INTERN)

DR.KRUPALATHA(INTERN)

DR.TEJASWINI(INTERN)

DR.RAMYA(INTERN)

DR.VAISHNAVI(PGY2)

DR. CHANDANA (PGY1)

DR. ARJUN(AP)

DR.HAREEN(SR)

DR. RAKESH BISWAS(HOD)

DIAGNOSIS-

ACUTE FULMINANT HEPATIC FAILURE SECONDARY TO ?POST INFECTIOUS(VIRAL/ BACTERIAL) ? TOXIN MEDIATED ? MISC

WITH HEPATIC ENCEPHALOPATHY

COAGULOPATHY

METABOLIC SEIZURES (? ABSENCE SEIZURES)

DKA RESOLVED

? DENOVO TYPE 1 DM

WITH THROMBOCYTOPENIA

CASE HISTORY AND CLINICAL FINDINGS-

Patient was apparently asymptomatic 6 months ago,then he noticed gradual loss of weight since 6months,patient had history of polyuria,nocturia,polydypsia since 2 months

10 days ago, patient attended a function outside and after 2 days he developed low backache and 2 episodes of vomitings and 3 episodes of loose stools for one day which subsided on its own.

Burning micturition is present

no h/o pain abdomen

blood tinged urine since 1 day

no h/o previous similar complaints

pt. got investigated outside (8/6/21)-

RBS-360MG/DL

(11/6/21)-TB-6.7

DB-3.9

ID-2.8MG/DL

pt. is using tab. glimy M1 since 3 days

VITALS-

TEMP-100.5F

PR-94/BPM

BP-110/70 MMHG

SPO2-100%

GRBS-211 MG%

CVS-

S1,S2 HEARD

RS-

BAE+

P/A-

TENDERNESS PRESENT IN RIGHT HYPOCHONDRIUM AND EPIGASTRIUM

INVESTIGATIONS-

CECT ABDOMEN -FATTY LIVER , NORMAL CBD ,NO IHBRD ,MILD ASCITIS ,INCIDENTALLY DETECTED SMALL BOWEL INTUSUSSCEPTION

CT BRAIN NORMAL

TREATMENT GIVEN-

COURSE IN THE HOSPITAL-

18 YEAR OLD MALE CAME WITH C/O LBA ,YELLOWISH DISCOLORATION OF EYES,FEVER SINCE 4-5 DAYS PT. WAS ADMITTED AND NECESSARY INVESTIGATIONS WERE SENT. PT WAS FOUND TO HAVE ISOLATED HYPERBILIRUBINEMIA(6.7TB )PREDOMINANTLY INDIRECT AND ENZYMES WERE NORMAL .HIS URINE FOR KETONES WERE POSITIVE WITH RBS 280 AND MILD ACIDOSIS .SO TH PT WAS DIAGNOSED AND TREATED AS DKA (DENOVO DETECTED TYPE 1DM),INDIRECT HYPERBILIRUBINEMIA UNDER EVALUATION,WITH COAGULOPATHY.USG ABDOMEN -LIVER NORMAL ECHOTEXTURE,CBD NORMAL ,NO EVIDENCE OF IHBRD

DAY1-

PT WAS TREATED WITH INSULIN AND IV FLUIDS,VIT K

DAY2-

HIS SUGARS CAME INTO CONTROL ON DAY2 OF ADMISSION .HIS INSULIN REQUIREMENT WAS AROUND 12 UNITS ACTRAPID PER DAY .PT CONTINUED TO HAVE LBA

XRAY LS SPINE WAS DONE WHICH WAS NORMAL

DAY3-

PT COMPLAINS OF LBA AND LOSS OF APPETITE AND DID NOT PASS STOOLS SINCE 1 DAY

SUPPORTIVE MANAGEMENT WAS GIVEN ,SYP LACTULOSE WAS GIVEN

DAY4-

PT COMPLAINED OF SEVERE GENERALISED WEAKNESS

BY AROUND EVNG 6 PM , PT BECAME DROWSY NOT RESPONDING TO VERBAL COMMANDS(?HEPATIC ENCEPHALOPATHY) WITH ACUTE RETENTION OF URINE AND BIZARRE STAREY LOOKS ,RESPONDING TO PAINFUL STIMULI ?ABSENCE SEIZURES ,INJ. LORAZ 2CC GIVEN

IN VIEW OF COAGULOPATHY CT BRAIN WAS DONE TO RULE OUT IC BLEED

CT BRAIN NORMAL

PT DID NOT PASS STOOLS SINCE 2 DAYS ,ENEMA WAS GIVEN

PT PASSED STOOLS AFTER ENEMA

FOLEYS CATHETERISATION WAS DONE ,COLA COLORED URINE OF ABOUT 1000 ML WAS COLLECTED IN UROBAG

URINE WAS SENT FOR ANALYSIS ,URINE FOR PORPHOBILINOGEN NEGATIVE ,NO RBCs IN URINE

UROLOGY REFERRAL WAS TAKEN IN VIEW OF 5MM RIGHT RENAL CALCULUS ,ADVISED FOR XRAY KUB AFTER STABILISATION

DENGUE SEROLOGY NEGATIVE,SMEAR FOR MP NEGATIVE

DAY5-

GCS- E2V2M3

PT COMATOSED WITH B/L REACTING PUPILS ,DILATED

VITALS STABLE ,DEEP TENDON REFLEXES NORMAL WITH B/L EXTENSOR PLANTAR

WITH SUSPICION OF CEREBRAL MALARIA ,INJ.FALCIGO 120 MG STAT. GIVEN(0----12---24--48 HRS), 4 DOSES GIVEN,INJ. LEVIPIL 500 MG BD WAS STARTED ,INJ. DOXYCYCLINE 100 MG BD WAS STARTED

OTHER SUPPORTIVE MEASURES WERE GIVEN SUCH AS IV FLUIDS ,SYP.LACTULOSE,ENEMA WERE GIVEN

HIS TB SHOOT UP TO 15 ,DB 6,IB 9,AST 18,ALT 22 ,ALP 138,TP 7.6,ALB 4,HB 13,(IT WAS 16 GM AT THE TIME OF ADMISSION )

DIFFERENTIAL DIAGNOSIS-

?CEREBRAL MALARIA

?ACUTE HEMOLYSIS(INTRAVASCULAR)

? ACUTE LIVER FAILURE (TOXIN MEDIATED)

? ACUTE INTERMITTENT PORPJHYRIA

HEPATIC ENCEPHALOPATHY WITH METABOLIC SEIZURES AND COAGULOPATHY

DKA (RESOLVED),DENOVO DETECTED ?TYPE 1 DM

DAY 6-

GCS-E2V1M3 WITH B/L REACTIVE PUPILS AND VITALS STABLE

SERUM LDH-237

SERUM IRON 150 ,SERUM FERRITIN> 1500,HBA1C 6.6,TSH 1

TRIPLE PHASE CT ABDOMEN WAS DONE TO RULE OBSTRUCTIVE PATHOLOGY WHICH SHOWED FATTY LIVER NO IHBRD ,NORMAL CBD ,NORMAL HEPATIC VEINS IVC,INCIDENTALLY DETECTED SMALL BOWEL INTUSUSSCEPTION

PERIPHERAL SMEAR -NORMOCYTIC,NORMOCHROMIC

SICKLING TEST NEGATIVE

FREE T3 3.86,FREE T4-1.41

D DIMER 2160

DAY 7-

GCS-E2V2M3

SUSPICION OF FUNGAL HEPATITIS ,INJ. FLUCONAZOLE 200 MG IV OD WAS STARTED ,INJ. CEFTRAIXONE 1 GM IV BD STARTED

IN VIEW OF UNEXPLAINED LIVER FAILURE N ACETYL CYSTEINE ,IV INFUSION WAS STARTED (600 MG)

WITH SUSPICION OF ANY CEREBRAL EDEMA ,3% NACL INFUSION WAS GIVEN FOR 1 DAY

GASTROENTEROLOGY REFERRAL WAS TAKEN : ACUTE FULMINANT HEPATIC FAILURE ,ADVISED FOR LIVER TRANSPLANTATION BUT PT ATTENDERS WERE NOT AFFORDABLE

DAY 8-

GCS-E1V1M3,VITALS STABLE

IN VIEW OF ACUTE FULMINANT LIVER FAILURE, HEPATIC ENCEPHALOPATHY PROBABILITY OF MULTISYSTEM INFLAMMATORY SYNDROME (POST COVID) WAS CONSIDERED .COVID ANTIBODIES WERE SENT WHICH SHOWED COVID ANTIBODY IGG >150(NORMAL IS <1),COVID ANTIBODY TOTAL VIA ELISA 5.85(NORMAL IS <0.8)

TB-12.6,DB-6.5,IB-6.1,AST 402,ALT 82 ,TP 6.8,ALB 4.1,HB 12.6,TLC5300,PLT 1.31

BY EVNG 7 PM PT SENSORIUM IMPROVED DRASTICALLY, PT WAS IRRITABLE AND COMPLETELY CAME INTO CONSCIOUS,PT WAS PASSING 2-3 STOOLS /DAY

GCS-E4V3M6

DAY 9-

PT RESPONDED TO COMMANDS,ORIENTED TO TIME,PLACE,PERSON ,VITALS STABLE

SERUM AMMONIA 108(NORMAL)

RTPCR COVID NEGATIVE

3% NACL WAS STOPPED AND REST ALL OTHER TREATMENT WAS CONTINUED

AT AROUND 6 PM ,PT HAD 1 EPISODE OF ? ABSENCE SEIZURE WITH VISUAL HALLUCINATION

DAY 10-

ACUTE FULMINANT HEPATIC FAILURE SCONDARY TO ? POST INFECTIOUS(BACTERIAL/VIRAL)? TOXIN MEDIATED ? MISC WITH HEAPTIC ENCEPHALOPATHY RESOLVED

COAGULOPATHY REOLVED ,DKA RESOLVED ,THROMBOCYTOPENIA RESOLVING WITH METABOLIC SEIZURES