A case of 36yr old male with jaundice
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.
A 36 yr old male presented to the OPD with C/O yellowish discolouration of eyes and passage of dark yellow coloured urine since 1month.
HOPI
Patient was apparently asymptomatic one month ago then he went to village for some occasion and developed fever and cough and was passing dark coloured urine. He visited a hospital and was diagnosed to be ?liver failure ( Total bilirubin- 5gm/dl) . 3 days later after getting back from the village he went to a hospital in Miryalaguda and then total bilirubin was 10 gm/dl for which he was given medication and alcohol abstinence. The patient continued drinking after completion of medication.He also used herbal medication for 9days but as he developed itching all over the body, he stopped taking the herbal medication.
Past history
The patient is not a known case of hypertension, diabetes, TB, epilepsy, asthma, CAD
He is a welding worker by occupation. He has normal appetite, mixed diet, regular bowel and bladder movements, adequate sleep. He is taking alcohol from last 20 years. He takes 180-360ml alcohol daily. He used to smoke 3cigerettes per day. He stopped smoking 4 years ago.
General examination
The patient is conscious, coherent and cooperative
He is moderately built and nourished
Vitals
Temperature: 98.6degree F
PR: 90bpm
BP: 120/70 mmHg
RR: 18cpm
SpO2: 98%
Icterus+
No pallor, cyanosis, clubbing, lymphadenopathy, edema
On examination
P/A Obese, non tender, no scars, no sinuses, hernial orifices free
Mild hepatomegaly
Splenomegaly
CVS S1 S2+
RS Bilateral air entry+, normal vesicular breath sounds+
CNS NFD
PROVISIONAL DIAGNOSIS
Chronic liver disease secondary to alcohol?
ECG
Treatment
Tab. UDILIV 300mg BD
Tab. MVT /PO/OD
Syp. LACTULOSE 15ml/PO/H/S
Inj. LORAZEPAM 2c.c /IV/SOS
IV Fluids (NS,RL,DNS) @50ml/hr
Tab. RIFAGUT 550mg BD
Inj. VITK 10mg/slow IV/ OD
Comments
Post a Comment