40 YR OLD MALE WITH YELLOWISH DISCOLORATION OF SCLERA.
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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:
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?
