35 yrs old M with yellow discoloration since 1week

-
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 .

This is a case of 35yr old presented to casuality with the complaints of yellowish discolouration of eyes since 1 week,
Dark coloured urine since 1 week.

HOPI:
                He was apparently asymptomatic 1 week back then he developed yellowish discolouration of eyes since 1 week which was insidious in onset,gradually progressive
Dark coloured urine since 1 week which is on and off .patient complaints of pale coloured stools since 1 week,not blood stained.
                   Patient complaints of swelling of both lower limbs,since 1 week extending upto the ankle,pitting type,aggrevated on walking and relieved by rest.  
       No complaints of pain abdomen,abdominal distension/bloating.
    No complaints of nausea,vomiting,chestpain,shortness of breath.

Past History:
         Not a known case of Dibetes,Hypertension,Tuberculosis,Asthma,Cva ,Cad,Thyroid disorders.

Family History:
      Not relevant .

Personal History:

      Diet: mixed
    Appettite:normal
  Bowel and bladder: Regular
      Sleep: Adequate
   -He is regular alcoholic since 10 yrs drinks 150ml per day
  -Doesnot smoke
 


GENERAL EXAMINATION 

Patient was conscious,coherent  cooperative

Moderately build and moderately nourished

well oriented to time ,place and person


Pallor : no pallorhttps://drive.google.com/uc?export=view&id=1tLLeo-cy3uhh90VtJt_fsT94JCliO9WGhttps://drive.google.com/uc?export=view&id=1DF1u3WIwPmq15FDJvHifAE1YDD_J6_dD

https://drive.google.com/uc?export=view&id=1Y0nSVlSYp6v2jseBN7VZNb7JIbNIQ88D
https://drive.google.com/uc?export=view&id=1709GXAzi8-_2RB4UPAQR9FYdnSCvnYfihttps://drive.google.com/uc?export=view&id=1JoQnb13PtvT6F8HaQlEnA_z1aTOLHsVk
Chest x-ray :https://drive.google.com/uc?export=view&id=1vk0oJnipCkx_iN3I7TSytmBRztr-FXcI
ECG:https://drive.google.com/uc?export=view&id=1k0nf1BIciPsg5bfar7HnIqsjCiF351ED


ABG :https://drive.google.com/uc?export=view&id=1fIn2gaFo8lmRvkq17NH5crFlj0WGJnMyhttps://drive.google.com/uc?export=view&id=1JQm4VfVCbaiR694AQUGFD6_PF-xPpbGo





Provisional diagnosis:
        Alcoholic Hepatitis
   

Treatment:

INJ.TREMADOL 1amp  100mlNS IV /SOS

INJ .UDILIV 300mg PO/BD

TAB.RIFACXMIN  550MG PO/BD 
TAB.MUCINOC  PO/BD
INJ.KCL 2AMP IN 500ML NS IV OVER 6 HRS

SYP.HEPAMERZ  15ml/PO/BD

SYP LACTULOSE PO/OD

TAB.PANTOP 40MG PO/OD
 
TAB.ULTRACET  1/2 tab. PO/BD

BP MONOTORING HOURLY

INJ.THIAMINE  1 amp in 100ml NS/IV/BD


Comments

Post a Comment

Popular posts from this blog

MY EXPERIENCES WITH GENERAL CELLULAR AND NEURAL CELLULAR PATHOLOGY IN A CASE BASED BLENDED LEARNING ECOSYSTEM'S CBBLE

-
 Myself tejaswini, young enthusiastic medical student welcoming to my medical cases blog journey  The first case that i have seen in the course of medicine is in my 3rd semester where the patient was lying on the bed and he looked so weak and when I approached the patient  he complained of fever since 2 days . He is also having body aches, headache and loss of appetite  I was so fasinatate to learn the pathophysiology of fever and causes and how it makes us physically and mentally weak. And the case was https://www.blogger.com/blog/post/edit/5638447817479559920/2371950410185238935 Through this case I learned the types of fever pattern and which can lead to diagnose a case through clinical approach  and how to make fever charts and diagnosis of fever based on type of raise wbc count .raised lymphocytes indicate viral fever and raised granulocytes indicate bacterial cause of fever.   Fever caused by virus would be sudden and high grade and would not last more than 1 week where as fever c
Read more

19 Year old male with fever and lower backache

-
Image
December 1,2022    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. DVN TEJASINI : roll no 40  This is a case of 19 year old male hailing from mirylaguda who is intermediate second year student came to general medicine OPD with chief complaints of  CHIEF COM
Read more

2 year old male child with fever,abdominal pain

-
Image
January  02 , 2023             PREFINAL PRATICAL EXAMINATION  DVN TEJASWINI  ROLL NO :40 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. The patient details were given by his mother A 2 and a half year old male child resident of miryalaguda came to general m
Read more