40 YEAR MALE WITH OBSTRUCTIVE JAUNDICE

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 evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 40 year old male who is a coconut vender came to casualty with c/o :
• constipation since 10 days
• Yellowish discoloration of sclera and urine from 3 days.
• cough(dry cough) since 2 days.
• throat pain since 2 days.

HOPI: 
Patient was apparently asymptomatic 3 years ago then he was diagnosed with hypertension since then he is on amplodipine , metaprolol , telma , clonidine.
9/4/2022- 
 He came to casualty with c/o :
• constipation since 10 days
• Yellowish discoloration of sclera and urine from 3 days.
• cough(dry cough) since 2 days.
• throat pain since 2 days.
PERSONAL HISTORY: 
He is an alcoholic since 25 years last binge 10 days ago.
• He is an occasional smoker.
GENERAL EXAMINATION: 
Pt is conscious, coherent, cooperative
Bp-120/80 mmHg
PR-81bpm
Temp -98.5°F
SpO2- 91%@RA
GRBS -116mg% @admission

CVS : S1 S2 +, Apex beat : 5th ICS mid clavicular line.

RS : BAE +, No crepts 

CNS : NAD

P/A : Soft, no tenderness . Bowel sounds +

Icterus + 

No pallor cyanosis, clubbing or lymphadenopathy.

PROVISIONAL DIAGNOSIS:
OBSTRUCTIVE JAUNDICE WITH HbsAG +


INVESTIGATIONS: 
CHEST X RAY:
ECG:
FINAL DIAGNOSIS: 
OBSTRUCTIVE JAUNDICE with HbsAG +

PLAN OF TREATMENT:
1. Tab. UDILIV 300 MG/PO/BD
2. Tab. RIFAXIMINE 550 MG/PO/BD
3. SYP. LACTULOSE 10ML /PO/TID
4. INJ. THIAMINE 2 amp in 100ml NS/IV/BD.
5. INJ. VITAMIN K 1 amp IV /OD.

Date:11/4/2022
SOAP NOTES (AMC bed 1) DAY 2
S- ABDOMINAL DISCOMFORT PRESENT.

O- PATIENT IS CONCIOUS,COHERENT,COOPERATIVE.
ICTERUS +
NO PALLOR ,CLUBBING,CYANOSIS,LYMPHADENOPATHY.

VITALS-
TEMPERATURE - 98 F
PULSE RATE - 78 BPM REGULAR ,NORMAL VOLUME
BLOOD PRESSURE - 150/70 MM HG
SPO2 - 98% AT RA
GRBS - 106mg/dl
On 

SYSTEMIC EXAMINATION - 
PER ABDOMEN : NON DISTENDED,SOFT NON-TENDER,NO GAURDING/RIGIDITY
CVS : S1 S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT,NORMAL VESICULAR BREATH SOUNDS
CNS : NAD




A - ALCOHOLIC LIVER DISEASE WITH ? ALCOHOLIC HEPATITIS ? OBSTRUCTIVE HYPERBILIRUBINEMIA WITH HbsAg +



P - REVIEW USG AND AWAITING FOR HbsAg ANTIBODIES AND VIRAL LOAD.

Date: 12/4/2022
SOAP NOTES (AMC bed 1) DAY 3
S- ABDOMINAL DISCOMFORT PRESENT.

O- PATIENT IS CONCIOUS,COHERENT,COOPERATIVE.
ICTERUS +
NO PALLOR ,CLUBBING,CYANOSIS,LYMPHADENOPATHY.

VITALS-
TEMPERATURE - 98 F
PULSE RATE - 78 BPM REGULAR ,NORMAL VOLUME
BLOOD PRESSURE - 150/70 MM HG
SPO2 - 98% AT RA
GRBS - 106mg/dl
On 

SYSTEMIC EXAMINATION - 
PER ABDOMEN : NON DISTENDED,SOFT NON-TENDER,NO GAURDING/RIGIDITY
CVS : S1 S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT,NORMAL VESICULAR BREATH SOUNDS
CNS : NAD




A - ALCOHOLIC LIVER DISEASE WITH ? ALCOHOLIC HEPATITIS ? OBSTRUCTIVE HYPERBILIRUBINEMIA WITH HbsAg +



P - REVIEW USG AND AWAITING FOR HbsAg ANTIBODIES AND VIRAL LOAD.

SOAP NOTES (AMC bed 1) DAY 4
S- C/O NAUSEA

O- PATIENT IS CONCIOUS,COHERENT,COOPERATIVE.
ICTERUS +
NO PALLOR ,CLUBBING,CYANOSIS,LYMPHADENOPATHY.
Viral load - >10000000

VITALS-
TEMPERATURE - 98 F
PULSE RATE - 74 BPM REGULAR ,NORMAL VOLUME
BLOOD PRESSURE - 130/80 MM HG
SPO2 - 98% AT RA
GRBS - 110 mg/dl

SYSTEMIC EXAMINATION - 
PER ABDOMEN : NON DISTENDED,SOFT NON-TENDER,NO GAURDING/RIGIDITY
CVS : S1 S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT,NORMAL VESICULAR BREATH SOUNDS
CNS : NAD




A - CHRONIC LIVER DISEASE WITH ? ALCOHOLIC HEPATITIS ? WITH HbsAg +



P - START TENOFOVIR?

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