03 Sai Tarun (august 3 2021)

  GENERAL MEDICINE CASE (25-07-21)


Welcome and greetings to every one who are visiting my blog. This is A.Sai Tarun of 3rd semester. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.

DATE OF ADMISSION - 30/07/21

Introduction

- A 37 year old male who is and agricultural labourer has jaundice from past 1month and was bought to the OPD.

HISTORY OF PRESENT ILLNESS

• C/O yellowish discolouration of scelera and urine from past 3 to 4 months.

•Chronic alcoholic from 5 to 6 years.

•Last alcohol intake was 3 days ago.

HISTORY OF PAST ILLNESS 

•NO H/O fever, pain abdomen, vomitngs, abdomen distension, pedal edema.

PERSONAL HISTORY

•Mixed diet

•Loss of appetite

•Sleep adequate

•Bowel and Bladder movements regular

•Regular alcohol drinker.

TREATMENT HISTORY 

 • Not k/c/o diabetes, HT, CAD , asthma, TB.

•NO H/O chemo /radiation , blood transfusion.

•NO H/O previous surgeries.

FAMILY HISTORY 

• Father has H/O Diabetes.

GENERAL EXAMINATION

•Patient is conscious, coherent and cooperative

•Moderately built and Moderately nourished

•No signs of - Pallor

                       Cyanosis

                       Clubbing

•Icterus present

VITALS

30/07/21

•Temp - 98.4
•Pulse rate - 74 BPM
•RP - 16/miM
•BP - 120/70 mm hg
•SPO2 - 98

31/07/21

•Pt c/c/c
•PR- 84bpm
•BP - 110/80 mm hg
•CVS s1 s2 +
•RS - BAE+ , NVBS
•P/A - soft
•CNS - NFND

01/08/21

•Pt c/c/c
•PR - 89bpm
•BP - 110/80 mm hg
•CVS s1 s2 +
•RS - BAE+ , NVBS
•P/A - soft
•CNS - NFND

02/08/21

•Pt c/c/c
•PR - 88bpm
•BP - 120/80 mm hg
•CVS s1 s2 +
•RS - BAE+ , NVBS
•P/A - soft
•CNS - NFND

•TEMP and PR - 4pm (100.6F AND 90bpm)
                            6pm (100.3F AND 96bpm)

03/08/21

•Pt c/c/c
•PR - 84bpm
•BP - 120/80 mm hg
•CVS s1 s2 +
•RS - BAE+ , NVBS
•P/A - soft
•CNS - NFND




SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

•S1, S2 heard

•No murmurs

RESPIRATORY SYSTEM:

•NVBS heard

•Position of trachea - central

•Breath sounds - vesicular

ABDOMEN

•Shape - scaphoid

•No Tenderness

•No palpable mass

•No free fluid

•Spleen and liver not palpable

CENTRAL NERVOUS SYSTEM:

•Intact

•No focal defect

•No abnormality detected

CEREBRAL SIGNS

• No finger nose incordination

•No knee heel incordination.


INVESTIGATIONS 

 








































UGIE REPORT



ULTRASOUND REPORT


ENDOSCOPY







PROVISIONAL DIAGNOSIS

- ALCOHOLIC LIVER DISEASE

TREATMENT 

30/07/21



31/07/21



01/08/21




02/08/21



03/08/21












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