64 year old man resident of bengal, is a farmer by occupation came with the complaints of yellowish discolortion of eyes since 1 month.

 This is an 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.


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. 


A 64 year old man resident of bengal, is a farmer by occupation came with the complaints of yellowish discolortion of eyes  since 1 month.


HISTORY OF PRESENT ILLNESS


History of low grade fever, intermittent, not associated with chills and rigor.

Patient also complaints of yellowish discoloration of urine since 1 month, passing of clay colored stools since 1 month.

He also complaints of itching all over the body since 1 month, decreased appetite, loss of weight and generalised weakness since 1 month.

Patient has pain in both knees since 6 months. 


HISTORY OF PAST ILLNESS 

No similar complaints in past.

No h/o diabetes 

No h/o hypertension 


PERSONAL HISTORY 

Diet -mixed 

Appetite - lost 

Bowel- regular 

Sleep -adequate

Addictions- no addictions


FAMILY HISTORY 

no family history 


TREATMENT HISTORY 

Patient had back pain in january for which he got treated at the local hospital in bengal. Pain relieved after taking medications.


GENERAL EXAMINATION 


Patient is consicous,cohorent,well oriented towards time place and person.


Pallor - absent 

Icterus-present 

 


Clubbing-absent 

Cyanosis-absent 

Lymphadenopathy - absent 

Edema-absent


VITALS 

Temperature-afebrile 

Pulse rate -92 

Respiratory rate- 22 bpm

Bp-100/60 


SYSTEMIC EXAMINATION 

CVS - S1 S2 (+)

Respiratory rate - BAE(+), NVBS (+)

Abdomen-

scaphoid ,

no tenderness,

no palpable mass,

Liver not palpable 

Spleen not palpable 

Bowel sounds -yes 


CENTRAL NERVOUS SYSTEM  

Patient is conscious with  higher functions intact 

REFLEXES  

                              RIGHT.                       LEFT.   


BICEPS                    +2                              +2


TRICEPS                  +2                               +2


SUPINATOR            +2                                +2


KNEE.                      +2                                 +2


ANKLE.                   +2                                 + 2




INVESTIGATIONS 











DIAGNOSIS: OBSTRUCTIVE JAUNDICE


TREATMENT  

1)Tab Zincovit 

2)Tab levocitrizine 10mg

3)Tab pregabalin 75mg

4)syp Lactulose 10ml

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