30 year old with fever and vomiting
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. 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
K.Phani Keerthana
Roll no 72
Cheif Complaints-
34 year old male lorry driver by occupation resident of chitiyal came to opd with chief complaints of Vomiting since 3 days
Hiccups since 3 days
Cough since 3 days
Loose stools for 1 day 3 days back
HOPI- patient was apparently asymptomatic 3 months back then he developed yellow discolouration of eyes associated with vomitings 5-6 episodes per day non bilious containing food particals for which he went to local hospital and diagnosed as jaundice and treated for it.
Then 3 days back then he had h/o vomiting 10-15 episodes/day sudden in onset,non bilious,non projectile,food and water as the contents
Vomiting is present immediately after food water and alcohol intake
Associated with generalised weakness
Loose stools- 4 episodes lasted for 1 day 3 days back
Non blood stained,large volume not associated with pain abdomen and fever, black coloured stools
Hiccups Since 3 days continuously, associated with mild difficulty in swallowing
Cough- dry since 3 days not associated with fever sore throat cold.
Past History-
Not a known case of Dm Tb epilepsy asthma CAD thyroid
Personal History
Diet- mixed
Appetite- decreased
Bowel and bladder- regular
Sleep- regular
Addictions- chronic alcoholic since 16years
Alcohol(beer) since 16 yrs daily 3 months back he has stopped Consuming alcohol as he was diagnosed with jaundice, but 5-10days back he again started consuming alcohol.
Increased consumption during night after dinner
Occasional toddy consumer
Family history
Not significant
General physical examination-
Patient is conscious coherent cooperative well oriented to time place and person moderately built and nourished
Pallor -absent
Icterus- present
Cyanosis- absent
Clubbing absent
Lymphadenopathy-absent
Edema-
Mild icterus
Vitals
Temperature- afebrile
RR-16/min
PR 75bpm
BP 130/70
Systemic examination-
Abdominal examination
On inspection
Abdomen flat
No distension
Umblicus is central
No engorged veins
No visible pulsations
No scars
Flanks are full
Palpation-
All inspectory findings are confirmed in Palpation
No tenderness
No guarding rigidity
No Hepatomegaly
No splenomegaly
Percussion-
Liver span 10 cm
Auscultation-
Bowel sounds are heard
Respiratory system-
Trachea is central
B/l air entry is present
Normal respiratory movements
Normal vesicular breath sounds
Cardiovascular system-
S1 and S2 heard no murmurs present
CNS examination
No focal neurological deficits
Investigations- LFT
Total bilirubin-2.66mg/dl
Direct bilirubin- 0.96mg/dl
SGOT- 593
SGPT- 275
ALP- 196
Serum electrolytes
Sodium 125
Chlorine- 82
Blood urea 142
Serum creatinine 4.1 mg/dl
Complete urine examination
Provisional diagnosis
Alcoholic liver disease
Treatment-
IVF-0.9% NS @ 100 ml / hr
RL@100 ml/ hr
Inj. Pantop 40 mg I/v Od
Tab baclofen 10 mg
Inj zofer 4 mg Iv TID
Inj thiamine.
Inj metoclopromide
Syp lactulose
Strict I/o charting
Comments
Post a Comment