55 Y/M With Fever and yellowish discoloration of eyes

 THIS IS AN 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE 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   

31- October -2023

55 year old male came to opd with chief complaints of fever and yellowish discoloration of eyes and tongue( jaundice) since 15days

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 15 days ago when he developed fever which was insidious in onset, low grade, gradually progressive in nature, associated with chills and rigors.

No hlo loose stools, vomitings

Pedal edema was noted by patient 2 days ago, pitting type

No h/o decreased urine output or burning micturation.

H/o cough since 1 day, non productive, dry cough.

No hlo chest pain, palpitations and sob

H/o yellowish discoloration of eyes and tongue since 15 days

No h/o bleeding per rectum, haematuria .

PAST HISTORY

K/c/o Diabetis mellitus II since 6 years, on unknown medication

N/k/c/o HTN, BA ,CVA , CAD , TB, Epilepsy

H/O Leprosy ? Hypopigmented patches ,7 months ago.

Medication one month ago?

No surgical history

H/o Blood transfusion , 5 days back. No reactions. Indications?

PERSONAL HISTORY

Married

Mixed diet

Decreased Appetite

Regular Bowel and bladder

No allergies 

Alcoholic since 20 years, stopped one year ago.

FAMILY HISTORY

Not significant 

GENERAL EXAMINATION:

Patient is conscious, coherent and co-operative,well oriented to time,place and person.

Moderately build and well nourished.

Examination was done in a well lit room.

Pedal edema + ( grade 2)

Icterus +

No pallor, cyanosis,clubbing,lymphadenopathy

Vitals

PR- 96 bpm

BP- 130/80 mm Hg

RR- 16 cpm

Temp -100 F

GRBS - 144 mg/dl

SYSTEMIC EXAMINATION

ABDOMEN 

Inspection

Shape - Slightly distention.

Umbilicus - Everted

Equal movements in all the quadrants with respiration.

No visible pulsation,peristalsis, dilated veins and localized swellings.

No scars , sinuses 

Palpation

Soft, non tender

Auscultation

Bowel sounds heard

RESPIRATORY SYSTEM 

Bilateral air entry present

B/L Crepts in ISA,IAA, Right Infra Mammary

Vocal resonance decreased

CVS EXAMINATION 

S1 S2 heard( Slightly muffled), no murmurs

CNS EXAMINATION 

No focal neurological deficits

Higher mental functions normal

Cranial nerves normal

Sensory examination normal sensations

Motor examination normal

Reflexes normal

INVESTIGATIONS

31/10/23

1 Nov 

2 NOV

3 NOV

PROVISIONAL DIAGNOSIS

? Drug induced hepatitis

K/c/o Leprosy

K/c/o DM II

Dapsone syndrome?

With anaemia 

TREATMENT

INJ.PIPTAZ 2.25 iv/ TID

INJ. Lactulose 10 mg PO/BD

INJ.Actrapid s/c according to GRBS

T. Dolo 650 mg PO/TID