42 year old male patient with yellowish discoloration of eyes and skin

42 year old male patient with yellowish discoloration of eyes and skin

18 February 2023

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42 year old male patient with yellowish discoloration of eyes and skin

Dr. M. Anurag ( Intern )

Roll no : 84

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.

CASE :  

42 year old male patient was brought to the casuality with chief complaints of 

1. Yellowish discolouration of eyes since 1 month

2. Yellowish discolouration of skin since 10 days

HOPI : 

Patient was apparently normal 1 month back then he yellowish discolouration of eyes which was insidious in onset, gradually progressive. 

Patient also has complaints of yellowish discolouration of skin since 10 days for which he was taken to a local hospital and was treated there.

Patient was unable to do his works from then and was lying on the bed and was not able to do his own works.

Patient also has complaints of vomitings since 4 days which was non projectile, non foul smelling with food particles as contents, non blood stained. 

Patient complained of abdominal distention and pain abdomen since 1 day for which he was taken to a local hospital and referred here from there.

There is history of loss of appetite , decreased urine output and high coloured urine. Stools are pale in colour and not passed today ( passed yesterday 2-3 episodes ).

Pedal edema is present but no facial puffiness.

PAST HISTORY : 

Not a k/c/o DM, HTN , TB ,epilepsy, asthma,CAD,CVD. 

H/O Splenectomy done in 2014 after a Road Traffic Accident. Also operated for fracture of radius and ulna of left arm.

Patient was given Pneumococcal and Hib vaccines after Splenectomy 

Patient was started on Tab. Librium 50mg BD after visiting a local hospital 10days back

PERSONAL HISTORY:

Appetite- Decreased since 1 month

Diet - mixed 

Bowel - regular 

Bladder - Decreased urine output and high coloured urine since 1 month

Addictions - 

1. Chronic alcoholic consuming 180ml everyday since 20 years

2. Chewable tobacco consumption since 20 years 

FAMILY HISTORY:

No significant family history 

GENERAL EXAMINATION:

Pt is C,C,C 

Icterus is present .

No pallor, cyanosis, clubbing, lymphadenopathy , pedal edema 

Vitals - 

Temp -98.6F

PR - 106bpm

BP - 110/80 mmhg

RR - 18cpm

SpO2 - 96% at Room air 

Grbs - 129

SYSTEMIC EXAMINATION :

PER ABDOMEN :

Inspection :

Umbilicus is central and inverted

All quadrants are moving equally with respiration 

Vertical Scar present over the abdomen.

No sinuses , engorged veins, visible pulsations .

Hernial orifices are free.

Palpitation :

Abdomen is firm in consistency.

Suprapubic bulge till umbilicus is present.

No organomegaly.

Liver - Not palpable 

Spleen - Splenectomy done in 2014 in KIMS,NKP

Percussion :  Tympanic note heard over the abdomen.

Auscultation:

Bowel sounds are heard.

CARDIOVASCULAR SYSTEM:

Inspection:

Shape of chest is elliptical. 

No raised JVP

No visible pulsations, scars , sinuses , engorged veins.

Palpitation:

Apex beat - felt at left 5th intercostal space

No thrills and parasternal heaves

Auscultation :

S1 and S2 heard. 

RESPIRATORY SYSTEM:

Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

No scars, sinuses, engorged veins, pulsations 

Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: resonant bilaterally 

Auscultation:

bilateral air entry present. Normal vesicular breath sounds heard.

CENTRAL NERVOUS SYSTEM:

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes Right Left

Biceps ++ ++

Triceps ++ ++

Supinator ++ ++

Knee ++ ++

Ankle ++ ++

INVESTIGATIONS:

CBP:

Hb - 8.3 gm/dl

TLC - 18800 cells/ cumm

RBC - 2.24 million

PLT - 3.45 lakh

RFT: 

urea - 16 mg/dl

Creatinine - 0.6 mg/dl

Na - 137 mEq/L

K - 3.6 mEq/L

Cl - 101 mEq/L 

LFT :

TB- 11.96 mg/dl

DB- 10.62 mg/dl

SGPT - 13 IU/L

SGOT - 40 IU/L

ALP - 394 IU/L

TP - 6.9

albumin - 2.5 gm/dl 

Chest X ray : 

ECG : 

USG - ABDOMEN : 

PROVISIONAL DIAGNOSIS:

DIRECT HYPERBILIRUBINEMIA SECONDARY TO CLD WITH MEGALOBLASTIC ANEMIA SECONDARY TO ALCOHOL

TREATMENT:

1. Salt restriction < 2gm /day 

2. Fluid restriction < 1.5 litres/day 

3. Inj. Thiamine 200mg IV TID in 100ml NS 

4. Inj. Optineuron 1 amp in 100ml NS 

5. Tab. Udiliv 300mg PO BD 

6. Syr. Lactulose 15ml PO OD H/S 

7. Abdominal Girth monitoring 

8. Weight monitoring 

9. Inj. Vit K 10mg slow OD 

10. Inj. Vit B 12 1000 mcg IM OD 

11. Tab. Folic Acid 5mg PO OD