A 27 year old male with generalised weakness since 20 days and yellowish discoloration of eyes since 2 years
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.
CHIEF COMPLAINTS:
Yellowish discoloration of eyes since 2 years
Swelling of feet since 20 days
Generalised weakness since 20 days
Loss of appetite since 20 days
Fever since 2 days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 2years back ,then his mother noticed that her son was frequently complaining of generalised weakness and not eating anything and then a week after she noticed yellowish discoloration of eyes ,for which she took him to hospital where they treated him in view of his addiction to alcohol and suggested him to abstain from alcohol. He took medication and stopped drinking for about a week and started consuming alcohol again. Then 8 months later he started having the similar complaints and was taken to hospital and doctor advised him to stop drinking alcohol but he did not listen and continued the habit.
Now since 20 days the patient started having generalised weakness which was insidious in onset and gradually progressive, associated with loss of appetite and swelling of feet confined upto ankle ,it increased on walking and decreases on lying down chest pain, palpitations, facial puffiness, decreased urine output.
Yellowish discoloration of eyes since 2 years which was insidious in onset,gradually progressive associated with high colored urine since 2 years and since 20 days patient complaints of darkly stained stools, only one such episode is reported in the past 2 years not associated with constipation, diarrhea.
Blood in urine since 10 days and not associated with decreased urine output ,increased frequency, urgency, burning micturition.
Patient is having low grade fever since 2days which is insidious in onset, gradually progressive ,intermittent, decreased on medication and not associated with chills, rigor, night sweats, evening rise of temperature, myalgia, joint pain, rashes.
H/o of tremors ,palpitations, fearfulness ,sweating if he stopped alcohol since 1 year
H/o hair loss since 2 years .
No complaints of difficulty in breathing, orthopnea ,PND, hemetemesis ,foul smelling breath, frequent bruises ,abdominal distension and abdominal pain ,nausea ,vomiting ,loose stools, confusion, altered sensorium ,lack of interest in work, decreased self care hygiene.
PAST HISTORY:
Two episodes of jaundice in the past two years for which he was taken to the hospital and declared a case of chronic liver failure .
N/k/O HTN ,DM ,TB, asthma ,heart disease, seizures
No history of blood transfusions, tattooing or IV drug abuse ,recent travel
TREATMENT HISTORY:
Deaddiction medication for a week 2 years back .
Diuretics in view of pedal edema
SURGICAL HISTORY:
Patient underwent appendectomy 4 years ago .
FAMILY HISTORY:
No similar complaints in the family
PERSONAL HISTORY:
27 year old male unmarried ,resident of miryalaguda ,a laborer by occupation
Finished education till 10 standard ,started consuming alcohol since the age of 21,initially consumed toddy later Whiskey since last 3 years, usual consumption -1/2 bottle of whiskey everyday (180ml)
not a known smoker
Not going to work since past 15 days
DIET -mixed
APPETITE -decreased since 2 years
BOWEL BLADDER - regular
SLEEP - increased sleepiness during day time since last 20 days
ADDICTIONS - alcoholic since 6 years
GENERAL EXAMINATION:
Patient is conscious, coherent and co operative well oriented to time, place and person
Patient is moderately nourished and moderately built
Height -5’7
Weight -48kgs
Pallor -absent
Cyanosis -absent
Clubbing -present (grade-2 increase in normal angle 160 * between nail bed and proximal nail fold )
lymphadenopathy -absent
Pedal edema - pitting type Upto ankle
Hair is sparse
No parotid swelling
Palmar erythema- absent
Gynaecomastia -absent
Pale colored nails -present
Tremors are present
Absent spider naevi
Petechae-absent
abdominal scar -midline extending from umbilicus to 1cm above pubic symphysis
Vitals:
Temperature-100.5 F
Blood pressure-110/80mm Hg
Pulse-74bpm
RR-17cpm,abdominothoracic
SYSTEMIC EXAMINATION:
ABDOMINAL EXAMINATION:
INSPECTION-
Abdomen is scaphoid in shape , no flank fullness
Umbilicus has scar contracture
Skin is normal with midline scar from umbilicus to 1cms above pubic symphysis below
No discolouration of skin ,engorged veins,sinuses
No visible peristalsis or pulsations
Hernial orifices Normal
PALPATION-
Abdomen is non tender , with rise of temperature due to fever
No guarding and rigidity
No organomegaly
PERCUSSION-
No fluid thrill
shifting dullness present
AUSCULTATION-
Bowel sounds heard
CNS EXAMINATION:
CARDIOVASCULAR SYSTEM EXAMINATION:
RESPIRATORY SYSTEM EXAMINATION:
Comments
Post a Comment