22YR OLD WITH VOMITINGS AND ICTERUS
This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians signed informed consent.
Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.
This Elog also reflects my patient centered online learning portfolio.
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 a diagnosis and treatment
CHIEF COMPLAINTS:::
PATIENT CAME TO OPD WITH C/O VOMITINGS SINCE 1WEEK
YELLOWISH DISCOLOURATION Of EYES SINCE 1WEEK
HISTORY OF PRESENT ILLNESS::
PATIENT WAS APPARENTLY ASYMPTOMATIC 1WEEK AGO THEN HE DEVELOPED VOMITINGS 3-4 EPISODES/DAY WITH FOOD MATERIAL AS CONTENT, NON BILIOUS, NON BLOOD TINGED, HISTORY OF ABDOMINAL Pain In EPIGASTRIC REGION 5DAYS AGO, NO H/O DIARRHEA
HISTORY OF HIGH GRADE FEVER 1WEEK Ago ASSOCIATED WITH CHILLS AND Rigor, CONTINOUS TYPE OF FEVER, RELIEVED ON MEDICATION
NO FEVER SINCE 5 DAYS
HISTORY OF MILD ITCHING OVER BOTH THIGH REGION
PAST HISTORY::
NOT A KNOWN CASE OF DIABETES MELLITUS, HYPERTENSION, ASTHMA, EPILEPSY, THYROID DISORDERS, CVD
NO SIMILAR COMPLAINTS IN PAST
::Family history::
Not relevant
Personal history::
Diet:mixed
Sleep :: adequate
Appetite:: decreased
Bowel and bladder:: regular
Addictions::occasional drinks alcohol( beer)
General examination::
After taking consent patient examined in a well lit room
Patient was conscious coherent cooperative
Well oriented to time ,place ,person
Thin built, nourishment moderate
No pallor
Mild icterus
No Lymphadenopathy
No cyanosis
No clubbing
No edema
Vitals
PR-78bpm
Bp-100/70 mmhg
RR--18cpm
Local examination::
Inspection..
Shape of abdomen...scaphoid
Umbilicus..inverted,central located
No sinuses or scars on abdomen
Palpation::
No rise in temperature
No Tenderness present
No palpable mass
No free fluid
Liver not palpable
Spleen not palpable
Percussion::
Dull note on right upper quadrant
No fluid thrill
No shifting dullness
Auscultation::
Bowel sound heard
Respiratory system::
B/L symmetrical elliptical
Trachea central
No sinuses ,scars
Normal vesicular breath sounds heard
Cardio vascular system::
S1s2 heard
JVP not raised
No murmurs
Central nervous system::
Speech normal
Cranial nerves intact
Sensory and motor system: normal
Reflexes.normal
Investigations::
Chest xray PA view::
ECG::
Serum creatinine::1mg/dl
Hemogram::
Hemoglobin.15. 9gm%
Total leucocyte count 4500
Neutrophils 49%
Lymphocytes 40%
Monocytes 10%
Eosinophils 01%
Basophils 0%
Platelet count 1.74lakh/mm on 15/6/23
Platelet count 1.15 lakh on 12/06/23
Mcv-89
Mch-30
Mchc-33.7
Complete urine examination::
pale yellow urine
Clear
Rbcs nil
Casts nil
Pus cells-2-3
Serum bilirubin-on 12/06/23 3.9mg/dl
Liver function tests::on 15/06/23
Total bilirubin:5.91mg/dl
Direct bilirubin:4.80mg/dl
Aspartate Transaminase:(AST)273 U /L
AlaninePhosphatese(ALP):316U /L
Alanine TRANSAMINASE(ALT) :817 U /L
TotalProteins:6.3g/dl
Albumin-3.57g/dl
Albumin/GlobulinRatio:1.31
Serum electrolytes::
Na+::146 mEq/L
K+::4. 4mEq/L
Cl-::102mEq/K
Ionized calcium::1.16
Prothrombin time 17sec
INR-1.25
APTT-34 sec
Serology-
HBSAGRAPID-NEGATIVE
HIV1/2RAPID-NON REACTIVE
ANTI HCV ANTIBODIES- Negative
Usg abdomen on 15/06/23
::Mild Hepatosplenomegaly
::Mild ascites
::GB WALL EDEMA
Inv on 16/6/23
TB-6.88
DB-6.62
AST-170
SGPT-841
ALP-170
TP-6.4
ALBUMIN-3.2
BH-14.5
TC-4100
PLATELETS-1.84
ON 17/06/23
TB-6.20
DB-5.23
AST-125
SGPT-651
ALP 293
TP-6.1
ALB-3.4
NA+-139
K+-4.5
CL-..102
ICA-1.19
HEPATITIS A VIRUS IGM ANTIBODY--2.86Provisional diagnosis:: viral pyrexia with Thrombocytopenia with acute liver injury( viral hepatitis)
Treatment ::
1.ivf-NS@75ml/hr
2.inj. Zofer 4mg iv/Tid
3.Tab.dolo650mg po sos
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