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:

USG 

5.2 mm calculus noted at lower pole of right kidney 

USG findings: Gross hepatomegaly,

Emphysematous pyelonephritis

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