A 36 year old male with yellowish discoloration of eye and urine

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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.This is an a 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.

P.Manogna Roll no.120

CASE REPORT 

A 36 year male came with chief complaints of :

Yellowish Discoloration of eyes and urine since 3months

HOPI :

Patient was apparently asymptomatic

14years back then he developed lower back pain and was diagnosed with renal caliculi  3months back  he developed

Yellowish discoloration of eyes and urine which did not subside on medication,  

vomitings with food particle as content, 

Fever which was insidious in onset,gradually progressive and subsided on taking medication 

Pain abdomen which was intermittent 

for which he was admitted in a local hospital for 3 days and diagnosed with chronic pancreatitis 

1 month back he had abdominal distention and Pedal oedema for which he took medication.

PAST HISTORY:

In 2012, he was diagnosed with TB for which he took a  6months course of medication 

In 2002 and 2014 he had similar complaints of yellowish discoloration of eye and urine for which he was treated.

He underwent a surgery for renal caliculi 

Not a known case of diabetes,HTN,epilepsy

PERSONAL HISTORY:

The diet he takes is mixed with decreased appetite,with inadequate sleep and regular bowel and bladder movements.

Addictions: history of alcohol intake since 20years( 180ml/day)

Chewing tobacco since 20years 

FAMILY HISTORY:

No significant family history 

GENERAL EXAMINATION: 

Patient is conscious, coherent,  and 

co-operative and well oriented to time and place.

He is moderately built and nourished 

Icterus-Present 

No Pallor,Clubbing, Cyanosis, Lymphadenopathy, edema

Other FINDINGS

Asterixis: positive 

https://youtube.com/shorts/WmYDnZJx-Ps?feature=share

VITALS:

Temp- 99.6 degree f 

PR -90 bpm

RR -24cpm

Bp -110/90 mmHg 

Spo2 - 98% 

GRBS- 148mg/dl

SYSTEMIC EXAMINATION:

CVS : S1,S2 heard 

RS: bilateral airway entry present,

normal vesicular breath sounds heard

trachea-central 

Per abdomen: soft,non tender,liver palpable bowel sounds heard 

CNS: no focal neurological deficits 

INVESTIGATIONS:

ECG:

USG:

2D ECHO:

PROVISIONAL DIAGNOSIS:

Alcoholic liver disease 

TREATMENT:

1. Inj.Pan40mg/IV/OD

2. Inj.Zofer4mg/IV/BD

3. Inj.Thiamine 2 Amp in 500ml NS/IV/TID over 2hours 

4. Inj.Optineuron 1 Amp in 100ml NS/IV/OD

5. Tab.Udiliv300mg/Po/BD

6. Tab.Rifqgut 550mg/po/BD

7. Syp.lactulose 10ml/po/BD

8.Soap water enema 

9. Abd.Girth daily 

10. Inj. Vit k 1Amp/IV/OD

11.monitor vitals 

12.fever chart daily 

13. Inj.Meropenum 1gm/IV/BD