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 evidence based input.
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 diagnosis and treatment plan.
A 44 year old male patient came to the hospital with chief complaints of fever with chills and rigor, shortness of breath, epigastric pain since 20 days and back pain on the left side since 10 days
HISTORY OF PRESENTING ILLNESS:
The patient was asymptomatic 15 years back and had history of intake of alcohol initially 90 ml which gradually progressed to daily intake of 300 ml of alcohol with no or minimal food intake. The patient developed high grade fever with chills and rigor. He was admitted to a hospital outside for a month and was treated as alcoholic liver disease with Total Bilirubin 23.7 gradually reduced to 2.5. The patient developed epigastric pain since past 20 days and back pain on the right side since 10 days.
Patient has decreased appetite and an episode of vomiting.
High grade fever with chills and rigor on and off
SOB on exertion
Pain in abdomen in left lumbar region, dragging type of pain
HISTORY OF PAST ILLNESS:
The patient was admitted to a hospital 4 years back with complaints of fever and was treated within 3 days.
N/K/H/O Diabetes, HTN, Asthma, TB, Epilepsy;
PERSONAL HISTORY:
Divorcee
Loss of appetite
Normal bowel movement (1 to 2 times per day)
Normal micturition (4 to 5 times per day)
Disturbed sleep due to pain since 20 days
Alcohol intake since 15 years
Tobacco chewing since 15 years (1 pack every 2 days)
PSYCHIATRIC HISTORY:
The patient tried to commit suicide 7 years back by intake of pesticide.
FAMILY HISTORY:
N/K/C/O DM, HTN, Epilepsy, TB, asthma;
GENERAL EXAMINATION:
No pallor
icterus present - yellowish discolouration of sclera
No cyanosis
No clubbing of fingers
No lymphadenopathy
VITALS:
Temperature- febrile
Pulse rate- 135 bpm
BP- 90/60 mm Hg
SpO2- 98%
GRBS- 85 mg/dl
SYSTEMIC EXAMINATION:
CVS:
S1, S2 heard, no murmurs
RESPIRATORY SYSTEM:
BAE +
P/A: obese, splenomegaly, no tenderness
CNS:
No abnormalities detected;
Glasgow scale- 15/15
PROVISIONAL DIAGNOSIS:
Alcoholic Liver Disease with alcohol dependence
INVESTIGATIONS:
CBC:
TREATMENT:
1) IVF NS @ 5 ML /HR ,RL,5 %D
2) INJ PANTOP 40.MG IV/OD
3)INJ ZOFER 4 MG IV/SOS
4) INJ NEOMOL 100 ML NS IV / SOS (IF TEMP GREATER 101 F )
5) TAB PCM 500 MG.PO/TID
6) I/O CHARTING
7) TEMP CHARTING
8) GRBS 6 TH HOURLY
9) SYP LACTULOSE 15 ML PO/HS
10) INJ TRAMADOL 1 AMP IN 100 ML NS IV/BD
11) VITALS 2ND HOURLY