This is an a 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.
Case
A 37 year old male presented to the opd with C/O Yellowish discoluration of eyes and passage of dark yellow coloured urine since 1 month.
HOPI:
Patient was apparently asymptomatic one month ago he went to his village for some occassion and he had fever and cough was tested dengue positive and was also diagnosed to be ?liver failure ( Total bilirubin- 5gm/dl) also he started to notice yellowish discoloration of the sclera and dark coloured urine, 3 days later he went to a local hospital in miryalaguda where scanning was done and then his total bilirubin was 10 gm/dl for which he was given some medication and alcohol abstinance, but the patient continued drinking . He also used herbal medication for a week as he developed itching all over the body he stopped taking the herbal medication.
He is married for 10 years, childless didn't get tested , significant alcohol history . Starting with white liquor around the age of 15-16 years it increased to cheap liquor / whisky ,daily intake of around 180 - 360 ml . H/o alcohol abstinance 2 years back for 1 year and resumed drinking last year . H/o smoking since 12 years , daily used to smoke 4 cigarettes. He stopped smoking since the last 4 years.
Past history:
Not a k/c/o DM , HTN, Asthma, epilepsy, CAD.
Personal history:
Diet - Mixed diet
Appetite - Normal
Bowel and bladder - Regular
Sleep - adequate
Addictions - Consumes alcohol regularly around 180- 360 ml/day.
H/o smoking since past 12yrs around 4 to 5 cigarettes/ day. He stopped smoking since the last 4 years .
Family history:
No significant family .
General examination:
Patient is conscious , coherant , cooperative .
He is oriented time, place, and person.
Moderately built and nourished.
ICTERUS-present .
There is no pallor, cyanosis , clubbing , lymphadenopathy, edema .
Vitals:
TEMP - 98.6 F
BP - 100/70 mmhg
PR - 82/ min
RR - 16 /min
SPO2 - 98 % ON RA.
Systemic examination:
CVS - S1, S2 heard, no murmurs heard.
RS - B/L air entry present, Normal vesicular breath sounds heard.
Abdomen -
- SHAPE OF ABDOMEN - OBESE
- ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION.
- NO SCARS AND SINUSES
- HERNIAL ORIFICES ARE FREE.
- Mild Hepatomegaly is present
- SPLEENOMEGALY IS PRESENT
- BOWEL SOUNDS -HEARD
CNS-
- HMF - INTACT
- CRANIAL NERVES EXAMINATION - NORMAL
- SENSORY SYSTEM- INTACT
- MOTOR SYSTEM EXAMINATON - NORMAL
CEREBELLAR EXAMINATION-
- FINGER NOSE COORDINATION - PRESENT
- KNEE HEEL COORDINATION - PRESENT
Provisional diagnosis:
Chronic liver disease secondary to Alcohol?
Investigations:
CBP:
HB- 10.2
TLC - 7800
PLT - 1.57
LYMPHOCYTES - 12
LFT:
TB- 15.9
DB - 7.10
AST - 366
ALT - 71
ALP - 358
TP- 7.2
ALB- 3.0
A/G - 0.71
CUE
COLOR - BROWNISH
APPERANCE - CLEAR
ALBUMIN - TRACE
SUGARS - NIL
BILE SALTS - NIL
BILE PIGMENTS - NIL
PUS CELLS - 2-4
EPITHELIAL CELLS - 1-3
RBC - NIL
BLOOD UREA - 12
S. CREAT- 0.5
15/11/21
LFT:
TB- 14.30
DB - 12.04
AST - 268
ALT - 56
ALP - 275
TP- 6.5
ALB- 2.62
A/G - 0.68
PT-20 sec
INR-1.4
aPTT- PROLONGED
LFT:
TB- 13.79
DB - 12.11
AST - 201
ALT - 46
ALP - 513
TP- 6.2
ALB- 2.6
A/G - 0.73
Xray Chest pa view:
USG abdomen:
Treatment:
-Tab. MVT /PO/OD
- syp.lactulose 15ml/PO/H/S
- inj. lorazepam 2c.c /IV/SOS
- IV Fluids (NS,RL,DNS) @50ml/hr
Comments
Post a Comment