Gen med case presentation;
Oct 30,2021
Name;Ramya reddy pebbeti.
Roll no;105 .
This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients’ clinical problems with collective current best evidence-based inputs. This e-log book also reflects my patient centred online learning portfolio and your valuable inputs on comment box is welcome.
I’ve 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
Following is the view of my case :
CASE PRESENTATION ;
DOA: 13/11/21
chief compliants; he works as welding worker in reddy lab in miryalaguda,he presented to the opd with c/o
Yellowish discoloration of eyes since 1.5month
Passage of Dark coloured urine since 1.5 month
Fever since 1 month (on and off )
HOPI; he was apparently asymptomatic 1.5 month ago, 45 days back he went to his sister's house for some festival ,there after 3 days he noticed yellowish discoloration of his eyes and some body pains and slight fever and cough for which he has taken to hospital and their the doctors asked him to admit in hospital as his bilirubin levels were high but he refused to join and they gave some medications. and after 2 days he came to his village miryalaguda and again he started drinking the local alcohol available near to his house twice daily for 3 days again he went to hospital in miryalaguda ,where he got done all his investigations in which bilirubin was turned out to be very high ,so hey asked him to admit in hospital ,but he didn't.they gave some medications but his symptoms didn't get relieved ,so he went to some village where they gave him herbal medication ,he used it for 9 days but there is no improvement and he noticed slight itching while taking the herbal medicine and he discontinued it .again he started drinking the same local alochol,the symptoms were worsening so he came to our hospital with yellowish discoloration of his eyes 👀 which was insidious in onset , gradually progressive and passage of Dark coloured urine since 1 month ,fever since 1 Month which is insidious in onset, intermittent,low grade type and associated with chills ,no aggravating factors , relieved on its own .
No H/o abdominal pain
No H/o vomiting
No H/o passage of loose stools
No H/o rash on his body
Past history;
No similar complaints in the past
He had no DM ,HTN,ATSHMA, EPILEPSY,CAD
Personal history;
Diet; mixed
Appetite; normal
Bowel and bladder;regular but dark coloured urine since 1 month,stools were normal in colour and consistency
Sleep ; adequate
Family history ; not significant
General examination;
Pt is c,c,c .well oriented to time ,place, person
He is moderately built and moderately nourished
PALLOR-present
ICTERUS-present
CLUBBING-absent
LYMPHADENOPATHY-absent
EDEMA-absent
VITALS;
TEMP:afebrile
PR:85 bpm
RR:15 cpm
BP:120/80 mm Hg
Inspection;
Shape of abdomen; distended
Position of umbilicus: central and inverted
No scars and sinuses are present
All quadrants are moving equally with respiration
No tenderness
Mild hepatomegaly is present
Percussion:
No fluid thrill and shifting dullness
Auscultation:
Bowel sounds are heard
Systemic examination;
RS: BAE+,NVBS
CVS: S1,S2 HEARD
CNS; INTACT
Provisional diagnosis:
CLD SECONDARY TO? ALCOHOL
Investigations;(on 13/11/21)
Hemogram:
Fever charting;
USG FINDINGS;
LFT;
Chest X- RAY;
On 15/11/21
LFT;
TB;14.30
DB;12.04
AST;268
ALT:56
Alkaline phosphatase;279
TP;6.5
Albumin;2.62
A/G RATIO;0.68
On 16/11/21
LFT;
TB;13.79
DB;12.11
AST;201
ALT;46
Alkaline phosphatase;513
TP;6.2
Albumin;2.6
A/G RATIO;0.73
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