Skip to main content

40 YR OLD MALE WITH YELLOWISH DISCOLORATION OF SCLERA.

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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.

A 40 year old male who is a coconut vender came to casualty with c/o :
• constipation since 10 days
• Yellowish discoloration of sclera and urine from 3 days.
• cough(dry cough) since 2 days.
• throat pain since 2 days.

HOPI: 
Patient was apparently asymptomatic 3 years ago then he was diagnosed with hypertension since then he is on amplodipine , metaprolol , telma , clonidine.
9/4/2022- 
 He came to casualty with c/o :
• constipation since 10 days
• Yellowish discoloration of sclera and urine from 3 days.
• cough(dry cough) since 2 days.
• throat pain since 2 days.
PERSONAL HISTORY: 
He is an alcoholic since 25 years  last binge 10 days ago.
• He is an occasional smoker.
GENERAL EXAMINATION: 
Pt is conscious, coherent, cooperative
Bp-120/80 mmHg
PR-81bpm
Temp -98.5°F
SpO2- 91%@RA
GRBS -116mg% @admission

CVS : S1 S2 +, Apex beat : 5th ICS mid clavicular line.

RS : BAE +, No crepts 

CNS : NAD

P/A : Soft, no tenderness . Bowel sounds +

Icterus + 


No pallor cyanosis, clubbing or lymphadenopathy.

PROVISIONAL DIAGNOSIS:
OBSTRUCTIVE JAUNDICE WITH HbsAG +


INVESTIGATIONS: 
CHEST X RAY PA VIEW:

USG ABDOMEN:

ECG

FINAL DIAGNOSIS: 
OBSTRUCTIVE JAUNDICE with HbsAG +

PLAN OF TREATMENT:
1. Tab. UDILIV 300 MG/PO/BD
2. Tab. RIFAXIMINE 550 MG/PO/BD
3. SYP. LACTULOSE 10ML /PO/TID
4. INJ. THIAMINE 2 amp in 100ml NS/IV/BD.
5. INJ. VITAMIN K 1 amp IV /OD.

Date:11/4/2022
SOAP NOTES (AMC bed 1) DAY 2
S- ABDOMINAL DISCOMFORT PRESENT.

O- PATIENT IS  CONCIOUS,COHERENT,COOPERATIVE.
ICTERUS +
NO PALLOR ,CLUBBING,CYANOSIS,LYMPHADENOPATHY.

VITALS-
TEMPERATURE - 98 F
PULSE RATE - 78 BPM REGULAR ,NORMAL VOLUME
BLOOD PRESSURE - 150/70 MM HG
SPO2 - 98% AT RA
GRBS - 106mg/dl
On 

SYSTEMIC EXAMINATION - 
PER ABDOMEN : NON DISTENDED,SOFT NON-TENDER,NO GAURDING/RIGIDITY
CVS : S1 S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT,NORMAL VESICULAR BREATH SOUNDS
CNS : NAD




A - ALCOHOLIC LIVER DISEASE WITH ? ALCOHOLIC HEPATITIS ? OBSTRUCTIVE HYPERBILIRUBINEMIA WITH HbsAg +



P - REVIEW USG AND AWAITING FOR HbsAg ANTIBODIES AND VIRAL LOAD.

Date: 12/4/2022
SOAP NOTES (AMC bed 1) DAY 3
S- ABDOMINAL DISCOMFORT PRESENT.

O- PATIENT IS  CONCIOUS,COHERENT,COOPERATIVE.
ICTERUS +
NO PALLOR ,CLUBBING,CYANOSIS,LYMPHADENOPATHY.

VITALS-
TEMPERATURE - 98 F
PULSE RATE - 78 BPM REGULAR ,NORMAL VOLUME
BLOOD PRESSURE - 150/70 MM HG
SPO2 - 98% AT RA
GRBS - 106mg/dl
On 

SYSTEMIC EXAMINATION - 
PER ABDOMEN : NON DISTENDED,SOFT NON-TENDER,NO GAURDING/RIGIDITY
CVS : S1 S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT,NORMAL VESICULAR BREATH SOUNDS
CNS : NAD




A - ALCOHOLIC LIVER DISEASE WITH ? ALCOHOLIC HEPATITIS ? OBSTRUCTIVE HYPERBILIRUBINEMIA WITH HbsAg +



P - REVIEW USG AND AWAITING FOR HbsAg ANTIBODIES AND VIRAL LOAD.

SOAP NOTES (AMC bed 1) DAY 4
S- C/O NAUSEA

O- PATIENT IS  CONCIOUS,COHERENT,COOPERATIVE.
ICTERUS +
NO PALLOR ,CLUBBING,CYANOSIS,LYMPHADENOPATHY.
Viral load - >10000000

VITALS-
TEMPERATURE - 98 F
PULSE RATE - 74 BPM REGULAR ,NORMAL VOLUME
BLOOD PRESSURE - 130/80 MM HG
SPO2 - 98% AT RA
GRBS - 110 mg/dl

SYSTEMIC EXAMINATION - 
PER ABDOMEN : NON DISTENDED,SOFT NON-TENDER,NO GAURDING/RIGIDITY
CVS : S1 S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT,NORMAL VESICULAR BREATH SOUNDS
CNS : NAD




A - CHRONIC LIVER DISEASE WITH ? ALCOHOLIC HEPATITIS ? WITH HbsAg +



P - START TENOFOVIR?

Comments

Post a Comment

Popular posts from this blog

A 30 year old male

Image
A 30 year old male November 23, 2022  This is an online e-log platform to discuss case scenario of a patient with their guardians permission.  A 30 year old male patient resident of Gudipally came to the casualty on 23/11/22 of altered behaviour since yesterday   Involuntary micturition since yesterday Giddiness since morning HOPI. Patient was apparently asymptomatic till 12 am last night then he started behaving abnormally which was sudden in onset in terms of not .responding when spoken to,irrelevant talk which is repetitive and self talking.patient is irritable every few minutes and abuses family members at times. Patient had history of alcohol consumption since 10 years currently 6 to 10 units daily throughout day,reports craving for alcohol, sweating and trembling when he doesn't consume alcohol.patient stopped consumption for the past 10 days till yesterday but was given 3 units I/v/o tremors @ 10:30 am which subsided after consumption . patient.also reported double images an
Read more

A 55 year old female patient came with chief complaint of shortness of breath

Image
A 55Yr old female with shortness of breath This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. 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. Cheif complaint: A 55yr old female patient residence of choutupal and agricultural by occupation with cheif complaint ofshortness of breath since 1 month and had an e
Read more

A 45yr old male c/o fever since 5 days. Abdominal pain, loose stools and vomitings

Image
A 45 yr old male c/o fever since 5 days.Abdominal pain , loose stools and vomitings CHIEF COMPLAINTS :    A 45 yr old male c/o fever since 5 days, abdominal pain , loose stools and vomitings since yesterday. HOPI: patient was apparently asymptomatic 5 days ago and then developed fever, which is low grade, not associated with chills and rigors and relieved on medication. He complains of diffuse pain abdomen since 11th October morning. He had 3-4 episodes of vomiting on the same day evening, food particles as content and non- bilious in nature .He had loose stools since evening the same day, which is of 5 -6 episodes and so he went to local hospital. He developed weakness of both upper and lower limbs and found to be having low potassium, correction was done and the weakness got improved. He now came with c/o abdominal pain , vomiting and loose stools. PAST HISTORY Not a k/c/o DM, Hypertension, Asthma, epilepsy, CAD, CKD.  He went for a General checkup 6yrs ago, where he was diagnosed
Read more