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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.
B.Gayathri Roll no :22
CASE
This is a case of 38yr old male presented with the chief complaints of pedal edema since 7 days ,epigastric pain since 7days
CHIEF COMPLAINTS:
Pedal edema since 7 days
Epigastric pain since 7 days
Yellowish discolourtion and epigastric pain since 6 days
HISTORY OF PRESENTING ILLNESS:
SEQUENCE OF EVENTS:
Patient was apparently asympomatic 1 month back then he noticed decreased appetite from past 30 days where he wanted to eat food but after taking 1-2 bites he cannot eat it.After eating some food he had nausea .
At the same time he also complained of intense burning micturition and also decresed urine output .
Both these symptoms have relieved now .
He had fever 15 days back that came for 3-4 days only during night and relieved by taking medication(DOLO at the time of fever).
Then he had motions .watery in consistency and he had 10 episodes per day.for about 10 days and have subsided now .
For motions and fever he consulted the hospital in his village There they gave him IV Glucose and some medication(They cant tell them) There they did some investigations and had confirmed that he has jaundice .For which the doctors their suggested the ayurvedic medicines for 10 days but after using it for 4 days as they obeserved no change they came to our hospital.
He has bilateral pedal edema pitting type which is extending from toe to knee since 7 days.
He now complaints of pain in epigastric region since 6 days and distended abdomen for which ascitic tap is done.(which is noticed by us he has no complaint about it)
He has generalised body weakness since 20 days.
He complaints of pus in urine and pain after urination.
DAILY ROUTINE:
He used to be a auto driver in past but now he is a agriculturer.(since 2020)
He wakes up at 6am and does his morning routine and eats his breakfast at 8am and goes to the field and does his work comes home in afternoon for lunch and again goes to do his work.He comes home in night at 7pm does his supper and sleeps.Now he is a daily wage labourer.
He is a chronic alcoholic where he drinks daily compulsory since 18yrs more than 300ml per day and drinks more during festivals.
PAST HISTORY:
He has nocturia 7-6 times for which he consulted doctor and was diagnosed as diabetic.in 2021
K/c/o diabetes since one year
Not a k/c/o HTN,Asthma,tuberculosis,Epilepsy.
PERSONAL HISTORY:
Diet:mixed
Appetite:decreased
bowel and bladder: regular
sleep:adequate
Addictions:Chronic alcoholic since 18yrs,smoker since 18yrs daily 1pack .
FAMILY HISTORY:
Not significant.
GENERAL EXAMINATION:
Patient was consious,coherent,cooperative.he is poorly built and malnourished and well oriented to time place and person.
Pallor: present
clubbing: absent
cyanosis:absent
Lyphadenopathy: absent
Edema : bilateral pedal edema pitting type from toe to hip.
VITALS:
BP: 120/80 mmHg
PR- 90 bpm
RR- 16cpm
GRBS: 100 mg/dl
SYSTEMIC EXAMINATION:
CVS: S1 and S2 heard no murmurs
Respiratory: bilateral air entry present
per abdomem-
Inspection:mild distended abdomen umbilicus everted
Palpation: soft and tendeeness in epigastric region
Percussion: shifting dullness is present.
CNS examination
HIGHER MENTAL FUNCTIONS:
Conscious, coherent, cooperative
Appearence and behaviour:
Emotionally stable
Recent,immediate, remote memory intact
Speech: comprehension normal, fluency normal
CRANIAL NERVE:
All cranial nerves functions intact
SENSORY FUNCTIONS
SPINOTHALAMIC TRACT
Pain , temperature ,presure- intact in all limbs
Posterior column:
Fine touch, vibration and proprioception are intact
MOTOR SYSTEM :
Right Left
Bulk:
Inspection. N. N
Palpation. N. N
Tone:
UL. N. N
LL. N. N
REFLEXES
B T S K A P
R 2+ - - - - Flexor
L 2+ - - - - Flexor
CEREBELLUM:
INVESTIGATIONS:
PROVISIONAL DIAGNOSIS:
Chronic liver disease associated with chronic pancreatitis.
FOLLOW UP:
30-06-22
Yesterday (29-06-22) morning he ate vada and some rice evening he took some rice again with dal.Till them he was relieved little bit -his motions were decreased epigastric pain was is reduced.
In night (8pm) he again had dairrhoea 8 times some times they were loose and sometime they were soft and had an episode of fever.
Treatment- DOLo 650mg for fever
For dairrhoea- Sporolac and Metrogyl
Salt restriction and fluid restriction for edema
Antibiotics for prostatic abscess.
01-04-22
He had breakfast -vada
Lunch- rice and dal
Dinner- rice and dal
After dinner he had loose stools 8-9 times but no episode of fever.
Treatment-
For diarrhoea-sporolac and metrogyl
Antibiotics for prostatic abscess
Salt and fluid restriction for edema.
02-07-22
/7/2022:
He complained of watery loose stools 7times at night .
Treatment:sporlac and metrozyl for loose motion
Diuretics for pedal edema.
Antibiotics for prostatic abscess.
4/7/2022:
4-5 times loose stools which are watery at night.
He complained of pus with blood in the urine.
Investigations:
CBP:
Hemoglobin - 6.4
TLC. - 8,700
Neutrophils - 67
Lymphocytes- 30
PCV. - 17.9
RBC. - 1.9 million cells /mcL
Platelets. - 2.9 lakhs
*Treatment:sporlac and metrozyl for loose motion
Antibiotics for prostatic abscess.
Diuretics for pedal edema.
Thiamine injection-200mg i.v
Hepamarz 10mg
Fluid restriction
5/7/2022:
Loose stools 4 times ,at night.
Epigastric pain is reduced when compared with the starting days.
Investigations:
CBP:
Hemoglobin -6.0
TLC. - 8,900
Neutrophils - 72
Lymphocytes- 22
PCV. - 2.8
RBC. - 1.9million cells /mcL
Platelets. - 2.8 lakhs.
Upper Gastrointestinal endoscopy:
*Treatment:sporlac and metrozyl for loose motion
Diuretics for pedal edema.
Antibiotics for prostatic abscess.
Thiamine injection-200mg i.v
Hepamarz 10mg
Fluid restriction.
6/7/2022:
Loose stools reduced.
Epigastric pain reduced.
*Treatment:
Diuretics for pedal edema.
Antibiotics for prostatic abscess.
Fluid restriction.
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