A 46 YEAR OLD MALE
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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.
A 46 yr old male came to the hospital with C/o pedal edema since 3 months
Yellowish discoloration of eyes and urine since 1 month
Bleeding per rectum since 1 month
HISTORY OF PRESENT ILLNESS:
Pt was apparently alright 3 months back then he had insidious onset of b/L pedal edema which is gradually progressive (initially upto ankle gradually progressed till knee ) pitting type , painless . Not associated with sob , orthopnea, pnd, decreased urine output . Took medications for pedal edema ,Releived on taking medications.
From 1 month patient has yellowish discoloration of eyes and urine associated with low grade fever relieved on taking medications,used herbal medications for this 1 month .Not associated with pain abdomen,vomitings,loose stools
From 1 month pt is having bleeding per rectum he was able to appreciate mass per rectum
PAST HISTORY:
No history of HTN,DM,asthma,TB, epilepsy
PERSONAL HISTORY:
Diet- mixed
Appetite- normal
Sleep- decreased from 1 month
Bowel and bladder regular
Addictions- Chronic alcoholic takes 270 ml/ day stopped 1 month back
TREATMENT HISTORY:
NSAIDS use from 2 months
FAMILY HISTORY: not significant
VITALS:
Bp- 120/80 mm hg
PR- 84 BPM
Grbs- 193 mg/dl
Temp- 98.5 F
RR- 20 cpm
Spo2 -99 percent on RA
ON EXAMINATION :
Pt is c/c/c
Patient is moderately built and moderately nourished.
No pallor, icterus, cyanosis, lymphadenopathy, Clubbing.
SYSTEMIC EXAMINATION :
CVS: S1, S2 heard, No murmurs.
RS: Position of trachea : Central
BAE : +
NVBS Heard.
P/A : Mild hepatomegaly + ( liver span:16 cms)
Bowel sounds+
CNS : NAD.
On examination pruritic hyper pigmented spots on trunk since 1 month , increased with onset of fever
PROVISIONAL DIAGNOSIS :
? Fevere with rash under evaluation
? Clinical malaria
With AKI ( Renal) secondary to toxins (NSAIDS)
with ? Denivo DM -2
With Hepatitis ( resolving) ? Alcoholic
? Viral
Surgery opinion in view of Grade 3 hemorrhoids and Grade 1 prostatomegaly
INVESTIGATIONS
14/8/21
On 15/08/21
Fever chart
TREATMENT:
On 15/8/21
1. INJ. Thiamine 1amp in 100 ml Ns IV/TID
2.TAB.Lasix 40 mg PO/BD
3.TAB. PCM 650 mg PO/SOS
4.I/O - CHARTING
5.BP/PR/ TEMP - 4th hrly
6. IVF NS
RL @ 75 ML/HR
7.SYRUP. cremaffin 10 ml/po/hs
8.Sitz with betadine
9.Ointment smuth for L/a
On 16/8/21
S: pedal odema since 3 months
Blood in stools since 1 month
O: pt c/c/c
Afebrile
Pedal odema pitting type bilateral upto knee
Hyperpigmented patches + on chest and trunk region which were increased after fever
PR -78 bpm
BP-110/80 mm Of hg
CVS -s1 and S2+
CNS NAD
R/S -NVBS +
P/A - soft
Tenderness + in right hypochondrium
Mild hepatomegaly +
Liver span 16 cms
Fevere with rash under evaluation
? Clinical malaria
With AKI ( Renal) secondary to toxins (NSAIDS)
with ? Denivo DM -2
With Hepatitis ( resolving) ? Alcoholic
? Viral
Grade 3 hemorrhoids and Grade 1 prostatomegaly
P: Inj lasix 40 mg iv /bd
Sup creamffin plus 15 ml Po/Bd
On 17/8/21
S: pedal odema since 3 months
Blood in stools since 1 month
O: pt c/c/c
Afebrile
Pedal odema pitting type bilateral upto knee
Hyperpigmented patches + on chest and trunk region which were increased after fever
PR -96 bpm
BP-130/70 mm Of hg
CVS -s1 and S2+
CNS NAD
R/S -NVBS +
P/A - soft
Tenderness + in right hypochondrium
Mild hepatomegaly +
Liver span 16 cms
Fevere with rash under evaluation
? Clinical malaria
With AKI ( Renal) secondary to toxins (NSAIDS)
with ? Denovo DM -2
With Hepatitis ( resolving) ? Alcoholic
? Viral
Grade 3 hemorrhoids and Grade 1 prostatomegaly
P: Inj lasix 40 mg iv /bd
Sup creamffin plus 15 ml Po/Bd
Inj.thiamine 1 amp in 100 ml NS/TID
INJ.buscopan/Im/sos
On 18 /8/21
S: pedal odema since 3 months
Blood in stools since 1 month
O: pt c/c/c
Afebrile
Pedal odema pitting type bilateral upto knee
Hyperpigmented patches + on chest and trunk region which were increased after fever
PR -90 bpm
BP-120/70 mm Of hg
CVS -s1 and S2+
CNS NAD
R/S -NVBS +
P/A - soft
Tenderness + in right hypochondrium
Mild hepatomegaly +
Liver span 16 cms
Fevere with rash under evaluation
? Clinical malaria
With AKI ( Renal) secondary to toxins (NSAIDS)
with ? Denovo DM -2
With Hepatitis ( resolving) ? Alcoholic
? Viral
Grade 3 hemorrhoids and Grade 1
prostatomegaly
? Drug induced erythema multiforme
? Viral exanthema
P: Inj lasix 40 mg iv /bd
Sup creamffin plus 15 ml Po/Bd
Inj.thiamine 1 amp in 100 ml NS/TID
INJ.buscopan/Im/sos
Orofer xt /po/bd
Sitz bath with betadine
Smuth ointment l/a
Calamine lotion all over the body
Tab.Teclizine 5 mg od
COURSE IN THE HOSPITAL: A 46 YR OLD MALE ADMITTED WITH
Clo pedal edema since 3 months
Yellowish discoloration of eyes and urine since 1 month
Bleeding per rectum since 1 month
PT WAS MANAGED CONSERVATIVELY WITH ABOVE MEDICATIONS, TAKEN SURGERY OPINION I/V/O CHOLELITHIASIS THEY ARE PLANNING FOR ELECTIVE CHOLECYSTECTOMY.TAKEN DERMATOLOGY I/V/O HYPERPIGMENTED PATCHES FOR THIS THEY ADDED CALAMINE LOTION AND TAB.TECLIZINE 5MG WITH IMPROVEMENT IN
OVERALL CANDITION AND RESOLUTION OF ABOVE MENTIONED SYMPTOMS PT IS BEING DISCHARGED WITH FOLLOWING AND ADVICED FOR FOLLOW UP ON SATURDAY TO GS AND GM OPD
Advice at Discharge
1.TAB.LASIX 40 MG /PO/BD FOR 3 DAYS 2.SYRUP CREMAFFIN 10 ML/PO/SOS 3.TAB OROFER XT/PO/BD FOR 7 DAYS
4.PROTIEN RICH DIET WITH 2 EGG WHITES/DAY
5.SITZ BATH WITH BETADINE
6.SMUTH OINTMENT L/A
7.CALAMINE LOTION ALL OVER BODY FOR 1 WEEK
8.TAB.TECLIZINE 5 MG /OD FOR 1 WEEK
