A 64 YR OLD MALE WITH CHOLESTATIC HEPATITIS
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 patient's clinical problems with collective current best evidence based inputs.
This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome."
I've 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 a diagnosis and treatment plan.
CASE:-
HISTORY OF PRESENT ILLNESS:-
A 64 year old man resident of bengal, is a farmer by occupation came with the complaints of
1) Yellowish discolortion of eyes since 1 month.
History of low grade fever, intermittent, not associated with chills and rigor.
2) Patient also complaints of yellowish discoloration of urine since 1 month, passing of clay colored stools since 1 month.
3) He also complaints of itching all over the body since 1 month, decreased appetite, loss of weight and generalised weakness since 1 month.
4)Patient has pain in both knees since 6 months.
Patient had back pain in january for which he got treated at the local hospital in bengal. Pain relieved after taking medications.
No history of palmar erythema, spider naevi, parotid swelling, no blood in urine.
HISTORY OF PAST ILLNESS:-
Not a known case of hypertension, diabetes, asthma, epilepsy, tuberculosis, CAD, CKD.
PERSONAL HISTORY:-
Patient takes mixed diet, appetite decreased ( used to eat thrice daily now takes meal only twice with decreased in quantity) since 1 month,
sleep adequate(sleeps about 6-7 hours at night, wakes up early in the morning for work).
Bowel and bladder habits are regular.
No addictions.
GENERAL EXAMINATION:-
On examination:
Patient is conscious, coherent
Vitals-
Temp: afebrile
PR:92 bpm
BP: 100/60 mm hg
RR: 22 cpm
GRBS: 90 mg /dl
Pallor-present
Icterus- present
No signs of cyanosis, clubbing, koilonychia, edema, lymphadenopathy.
PER ABDOMEN: soft, non tender
CVS: S1S2 heard
RS: BAE +, NVBS+
CNS: NAD
Investigations:
Hb: 8.9 gm/ dl
Tlc:7,900 cells/mm3
Platelets: 3.31 lakhs/mm3
Total bilirubin: 6.9
Direct bilirubin: 2.85
AST:64
ALT:55
ALP:1,141
Total proteins:6.3
Albumin:2.4
Sr.urea:20 mg/dl
Sr. Creatinine: 0.8
Uric acid: 2.1
FreeSodium: 134
Potassium:04
Chlorine:98
Date:- 23/10/21
Ultrasound: no sonological abnormality
REVIEW ULTRASOUND FOR GB PATHOLOGY
Diagnosis: INTRAHEPATIC CHOLESTATSIS
Date:- 20/10/21
Date :-21/10/21
S:- ITCHING+
YELLOWISH DISCOLORATION OF SCLERA
DIDN'T PASSED STOOLS
SLEEP REDUCED.
O:
Patient is c/c/c
Temp: 98.9°f
BP: 110/70mmhg
RR: 21cycles / min
PR: 89Bpm
CNS: HMF intact.
CVS: S1 S2+ , no murmurs
RS:BAE+, NVBS +
P/A: soft,non tender
Hb: 8.9 gm/ dl
Tlc:7,900 cells/mm3
Platelets: 3.31 lakhs/mm3
Total bilirubin: 6.9
Direct bilirubin: 2.85
AST:64
ALT:55
ALP:1,141
Total proteins:6.3
Albumin:2.4
Sr.urea:20 mg/dl
Sr. Creatinine: 0.8
Uric acid: 2.1
FreeSodium: 134
Potassium:04
Chlorine:98
A:
OBSTRUCTIVE JAUNDICE
23/10/21
S: itching+
Weakness+
Yellowish discoloration of sclera+
O:on examination patient is conscious, coherent, cooperative
Vitals:
BP-110/70 mm hg
PR-78 bpm
RR-18 cpm
TEMP-98.2 f
CVS:- S1 S2+
RS:- BAE+ , NVBS+
PA:- SOFT ,NON TENDER
A: Obstructive jaundice
P:
Treatment:
1)tab.zincovit po/od
24/10/21
S: itching+
Weakness+
Yellowish discoloration of sclera+
Knee joint pain+
O:on examination patient is conscious, coherent, cooperative
Vitals:
BP-110/70 mm hg
PR-80 bpm
RR-18 cpm
TEMP-98.2 f
CVS:- S1 S2+
RS:- BAE+ , NVBS+
PA:- SOFT ,NON TENDER
A: Obstructive jaundice
P:
Treatment:
1)Tab.zincovit po/od
2) Tab . Levocitrizine 10 mg p/o od
3) Tab . Pregabalin 75 mg p/o od
25/10/21
S: itching subsided
Weakness+
Yellowish discoloration of sclera+
Knee joint pain+
Numbness in both UL and LL
O:on examination patient is conscious, coherent, cooperative
Vitals:
BP-110/70 mm hg
PR-78 bpm
RR-18 cpm
TEMP-98.2 f
CVS:- S1 S2+
RS:- BAE+ , NVBS+
PA:- SOFT ,NON TENDER
A: Obstructive jaundice
P:
Treatment:
1)Tab.zincovit po/od
2) Tab . Levocitrizine 10 mg p/o od
3) Tab . Pregabalin 75 mg p/o od
4) Syp. LACTULOSE 10ML P/O OD
CONSTRUCTIONAL APRAXIA FOR HEPATIC ENCEPHALOPATHY.
Date:-26/10/21
S: itching subsided
Weakness+
Yellowish discoloration of sclera+
Knee joint pain+
O:on examination patient is conscious, coherent, cooperative
Vitals:
BP-100/60 mm hg
PR-79 bpm
RR-18 cpm
TEMP-98.2 f
CVS:- S1 S2+
RS:- BAE+ , NVBS+
PA:- SOFT ,NON TENDER
A: CHOLESTATIC HEPATITIS
P:
Treatment:
1)Tab.zincovit po/od
2) Tab . Levocitrizine 10 mg p/o od
3) Tab . Pregabalin 75 mg p/o od
4) SYP. LACTULOSE 10ML P/O BD.
27/10/21
S: itching subsided
Weakness+
Yellowish discoloration of sclera+
Knee joint pain+
Numbness in LL +
O:on examination patient is conscious, coherent, cooperative
Vitals:
BP-110/60 mm hg
PR-81 bpm
RR-18 cpm
TEMP-98.2 f
CVS:- S1 S2+
RS:- BAE+ , NVBS+
PA:- SOFT ,NON TENDER
A: INTRAHEPATIC CHOLESTATSIS
P:
Treatment:
1)Tab.zincovit po/od
2) Tab . Levocitrizine 10 mg p/o od
3) Tab . Pregabalin 75 mg p/o od
4) SYP. LACTULOSE 10ML P/O BD.
5) TAB .PCM 500 MG SOS
