30YR OLD MALE WITH VOMITINGS AND B/L LOWER LIMB SWELLING, PAIN ,TINGLING OF ALL 4 LIMBS

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Patient came with complaints of
             Vomitings since 3months
Patient was apparently asymptomatic 3years ago then he developed B/L lower limb swelling and pain.tingling of all four limbs unable to walk along with chest heaviness for which cardiac consultation was done (normal study) followed by urine discoloration to red /yellow 
Liver and kidney consultations were taken during which Hb was 24 and hba1c-9 was diagnosed with HTN and DM 
      Neurological consultation was taken i/v/o tingling sensation and inability to walk and was diagnosed motor axonal neuropathy of B/L CPN and B/L sural nerves secondary to DM.
        He was referred to NIMS Hyd for hematological consultation and was diagnosed as polycythemia vera(triple negative-JAK 2,CAL-R,MPL) idiopathic myeloplastic neoplasia and phlebotomies were done in 1year span during which patient remained teetotaller ,non smoker.
        From 3months patient started drinking again and he developed generalised weakness, vomitings(food as content,non bilious,non projectile,non blood tinged aggregated in early morning, relieved after drinking)
       C/o loss of appetite, abdominal bloating sensation,dark colored urine since 3months associated with belchings

Past history
K/C/O HTN since 3years(on TELMA 20mg PO/OD)
K/C/O DM2 Since 2years(not on medication)
H/O phlebotomies in the past
Not a k/c/o CAD,CVD, Asthma,epilepsy.

Personal history 
Diet-mixed
Sleep- adequate
Appetite-lost since 3months
Bowels-irregular(daily once but not smooth and on CREMAFFIN)
Micturition-normal
Addictions -chronic alcoholic since 12yrs
                  Drinks 12units/day(1unit-                               300ml)since 3months
Smoking -stopped 2years ago
Allergies-none

Family history -
Not significant 

General examination 
Patient was conscious, coherent, cooperative and well oriented to time and place. 
Moderate built and moderate nourished 
No pallor, Icterus, Cyanosis, clubbing, pedal edema, Lymphadenopathy.

Vitals:
BP: 130/100mmhg
PR:84bpm
RR: 20 cpm
GRBS: 165 mg/dl
SPO2: 98% at RA


Systemic Examination 
CVS:S1 S2+. No murmurs
RS:BAE+
CNS: 
GCS -E4 V5 M6
Power- UL. 5/5. 5/5
                LL. 5/5. 5/5
Tone- UL. N. N
          LL. N. N
Reflexes:
             B. 3+. 3+
             T. 2+. 2+
             S  1+. 1+
             K. 2+ . 2+
             A. 1+. 1+
       Plantar flexion. flexion 
P/A. Soft,non tender,no organomegaly 

Investigations :
Ecg
2d echo
USG-
   Gallbladder sludge
    Right renal calculus
    Grade 2 fatty liver

Serum ferritin-83.1ng/dl
Serum iron-123microg/dl

DIAGNOSIS-
ALCOHOLIC GASTRITIS with
   K/C/O POLYCYTHEMIA VERA(JAK2 negative)with HTN SINCE 2yrs and TYPE 2 DM SINCE 2yrs

TREATMENT-
1)INJ THIAMINE 400mg in 100ml NS.        IV/STAT

2)INJ PANTOP 40mg IV/STAT

3)INJ ZOFER 4mg IV/STAT

4)TAB.TELMA 20mg PO/OD

5)TAB.NICARDIA 10mg PO/STAT


Day 2 (18/08/23)
S:
Vomitings subsided 
Tremors present
O:
       Patient was conscious, coherent, cooperative
Vitals:
BP: 130/90mmhg
PR:96bpm
RR: 18 cpm
GRBS: 148 mg/dl
SPO2: 98% at RA

Systemic Examination 
CVS:S1 S2+. No murmurs
RS:BAE+
CNS: 
GCS -E4 V5 M6
Power- UL. 5/5. 5/5
                LL. 5/5. 5/5
Tone- UL. N. N
          LL. N. N
Reflexes:
             B. 3+. 3+
             T. 2+. 2+
             S 1+. 1+
             K. 2+ . 2+
             A. 1+. 1+
       Plantar flexion. flexion 
P/A. Soft,non tender,no organomegaly
Investigations 
FBS-132mg/dl
Hba1c-6.9%
Plbs-231mg/dl
Lipid profile
A-ALCOHOLIC GASTRITIS with
   K/C/O POLYCYTHEMIA VERA(JAK2 negative)with HTN SINCE 2yrs and TYPE 2 DM SINCE 2yrs
With motor axonal neuropathy (B/L LL)With alcohol dependence syndrome


P-
1)INJ THIAMINE 400mg in 100ml NS. IV/STAT

2)INJ PANTOP 40mg IV/STAT

3)INJ ZOFER 4mg IV/STAT

4)TAB.TELMA 20mg PO/OD

5)TAB.NICARDIA 10mg PO/SOS
(If Bp>160/100mm Hg)

6)TAB.LORAZEPAM 2mg po/od

7)TAB.PREGABALIN -M 75 po/sos

8)TAB.ECOSPIRIN AV(75/20)PO

Day 3(19/08/23)
S-stools passed
Tremors present 
O-:
       Patient was conscious, coherent, cooperative
Vitals:
BP: 140/80mmhg
PR:106bpm
RR: 18 cpm
GRBS: 156 mg/dl
SPO2: 98% at RA

Systemic Examination 
CVS:S1 S2+. No murmurs
RS:BAE+
CNS: 
GCS -E4 V5 M6
Power- UL. 5/5. 5/5
                LL. 5/5. 5/5
Tone- UL. N. N
          LL. N. N
Reflexes:
             B. 3+. 3+
             T. 2+. 2+
             S 1+. 1+
             K. 2+ . 2+
             A. 1+. 1+
       Plantar flexion. flexion 
P/A. Soft,non tender,no organomegaly
Investigations 


A-ALCOHOLIC LIVER DISEASE with MILD HEPATITIS With motor axonal neuropathy (B/L LL)With alcohol dependence syndrome
   K/C/O POLYCYTHEMIA VERA(JAK2 negative)with HTN SINCE 2yrs and TYPE 2 DM SINCE 2yrs

P-
1)INJ THIAMINE 400mg in 100ml NS. IV/STAT

2)INJ PANTOP 40mg IV/STAT

3)INJ ZOFER 4mg IV/STAT

4)TAB.TELMA 20mg PO/OD

5)TAB.NICARDIA 10mg PO/SOS
(If Bp>160/100mm Hg)

6)TAB.LORAZEPAM 2mg po/od

7)TAB.PREGABALIN -M 75 po/sos













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