Q: Uh, 32-year-old male patient come in OPD with no history of alcoholic and, uh, cigarette smoking. The patient come in OPD with complaint of epigastric discomfort, uh, gas shown positive with history of renal calculi in all calyx near about 2 mm each, per-abdomen tenderness, and having marks on skin past two years, uh, cured with ayurvedic medicine unknown. Epigastric dysfunction and, uh, the patient is now, uh, having no pain in abdomen after giving the medications. Like, uh, tramadol, PCM 1 gram, levosulpride, and pantoprazole 40 mg, and, uh, RL and, uh, MVI with, uh, NS 500. Also, the patient given, uh, buscopan injection and, uh, as well as voveran injection in NS 100. Uh, the patient is now settled most probably, but showing some gasping, or you can say, uh, breathing issues having, uh, dyspnea-like function, dyspnea-like symptoms, uh, साँस लेने में तकलीफ होना और साँस खिंचा-खिंचा आना। And what was the probable diagnosis? And the treatment? No. A: This patient should be sent to an emergency department now, not managed further as simple gas/renal-colic pain. Main concern The reports show marked acute liver-cell injury: - AST/SGOT 768 U/L and ALT/SGPT 650 U/L - Mild leukocytosis with neutrophilia: WBC 12.3, granulocytes 90.4% - Mildly elevated CRP: 10.89 mg/L - Creatinine 0.86 and urea 30: kidney function currently looks preserved. - ECG print says sinus bradycardia, 56/min, with no definite acute ischemic diagnosis on the machine interpretation. A photograph cannot reliably exclude cardiac disease. The 2 mm calyceal renal stones are usually not enough to explain these liver enzymes or breathing difficulty. Probable working diagnosis Acute hepatitis / acute hepatocellular liver injury, until proven otherwise. Important possibilities include: 1. Drug-induced or herbal medicine-induced liver injury Unknown Ayurvedic medicine is a significant possibility. Diclofenac Voveran can also rarely cause liver injury. Paracetamol/PCM is particularly important to assess because it can cause severe acute liver damage in overdose or with unrecognized cumulative dosing. 2. Acute viral hepatitis, especially hepatitis A, E, B, or less commonly C. 3. Adverse drug reaction or anaphylaxis-like reaction causing the new breathing difficulty, particularly if it began after tramadol, diclofenac, hyoscine/Buscopan, IV fluids, or another injection. Rash, lip/face/tongue swelling, wheeze, low blood pressure, faintness, or rapidly worsening breathlessness would make this an immediate resuscitation emergency. 4. Less likely but must be ruled out: biliary obstruction, ischemic liver injury, autoimmune hepatitis, or another toxin. Current hepatology guidance considers AST/ALT above 5 times the upper limit clinically significant and recommends immediate discontinuation of suspected agents with assessment of bilirubin and INR. AASLD DILI guidancehttps://pmc.ncbi.nlm.nih.gov/articles/PMC9936988 supports this approach. Drug-induced liver injury can result from prescription drugs or herbal products. Goldman-Cecil Medicine, drug-induced liver injury section. Immediate treatment priorities At hospital, the clinician should: - Check ABC immediately: respiratory rate, work of breathing, SpO2, BP, pulse, mental status. - Give oxygen if hypoxemic, obtain IV access, continuous monitoring. - If there is wheeze/stridor, facial swelling, urticaria, hypotension, or rapidly progressive dyspnea: treat as possible anaphylaxis, with prompt IM adrenaline/epinephrine, airway support, oxygen, and IV fluids under emergency supervision. Delay in epinephrine increases risk in true anaphylaxis. Textbook of Family Medicine, manifestations of anaphylaxis. - Stop and do not repeat unknown Ayurvedic medicines, diclofenac/Voveran, paracetamol/PCM, tramadol, and nonessential medicines until a doctor reviews the liver injury. Do not self-medicate or take alcohol. - Specifically establish all paracetamol taken in the previous 24-72 hours, including combination tablets. If overdose or uncertain exposure is possible, emergency clinicians should check a paracetamol level and consider N-acetylcysteine NAC without unnecessary delay. Urgent tests - Repeat LFT: AST/ALT, bilirubin, ALP, GGT, albumin - PT/INR urgently: this determines liver synthetic function - Blood glucose, electrolytes, ABG/VBG if breathlessness, lactate - Hepatitis A IgM, hepatitis E IgM, HBsAg and anti-HBc IgM, anti-HCV as indicated - Paracetamol level and toxicology/drug history - Ultrasound abdomen with hepatobiliary assessment - Chest examination, chest X-ray, serial ECG and troponin if chest symptoms or unexplained dyspnea - Consider eosinophil count and assessment for rash/drug hypersensitivity Danger signs requiring ambulance/emergency care immediately - SpO2 below 94%, worsening shortness of breath, wheeze, blue lips - Lip/tongue/facial swelling or generalized rash - Confusion, unusual sleepiness, agitation, fainting - Jaundice, dark urine, persistent vomiting - Bleeding/bruising, very low urine output, severe abdominal pain - Fever with worsening condition The current breathing complaint plus AST/ALT in the 600-700s makes this an urgent acute medical assessment, even if abdominal pain has settled.
