Name: K.sannith reddy
Roll no. 65
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 a diagnosis and treatment plan.
Following is the view of my case :
44 yr old male pt came to the casualty with
c/o loss of appetite since 1 month
cough with expectoration since 10days
sob (grade4) since 4 days
pt was apparently asymptomatic 10 years back then he developed loss of appetite ,yellow discoloration of sclera ,he went to local hospital and was told he had jaundice releived on taking herbal medication for 10 days
then he was fine till one month back then hep developed loss of appetite since then he had decreased intake of food then he developed cough with expectoration sputum os scanty whitish in colour cough increases at night then he devoloped Sob(grade 4) since 4days
no h/o fever ,cold, body Pains,headache,nausea,vomiting ,chestpain , Palpitations,orthopnea,pnd
PAST HISTORY
N/K/C/O HTN,DM,ASTHMA,TB, EPILEPSY,CAD
PERSONAL H/O:
APPETITE DECREASED
DIET MIXED
SLEEP: ADEQUATE
BOWEL AND BLADDER: REGULAR
NO KNOWN ALLERGIES
FAMILY HISTORY: NOT SIGNIFICANT
GENERAL EXAMINATION:
PT IS C/C/C
WELL ORIENTED TO TIME ,PLACE AND PERSON
NO PALOR, ICTERUS ,CYANOSIS, LYMPHADENOPATHY, EDEMA
VITALS AT ADMISSION:
BP: 100/60MMHG
PR: 120BPM
RR: 18CPM
SPO2: 90%AT RA
SYSTEMIC EXAMINATION:
CVS - S1 S2 + NOMURMURS,JVP NOT RAISED
RS - BAE + , CREPTS + IN LEFT IAA AND LT.ISA
REMAINING AREAS NVBS HEARD
OTHER AREAS- NVBS HEARD
P/A - SOFT NON TENDER, ON PERCUSSION TYMPANIC NOTE HEARD ,BS +
CNS -
RHOMBERG POSITIVE
GAIT NORMAL
MOTOR UL LL
POWER. RT 5/5. 5/5
LT 5/5. 5/5
TONE. RT N N
LT N N
INVESTIGATIONS:
USG ABDOMEN : IMPRESSION- GRADE 1 FATTY LIVER
CHEST X RAY :
DIAGNOSIS:
)? ALCOHOLIC LIVER DISEASE
2)RIGHT MIDDLE LOBE CONSOLIDATION..? CAP.? TB
3) BICYTOPENIA WITH ANEMIA UNDER EVALUATION. ? B12 DEFECIENCY SECONDARY TO ALCOHOL
4)WITH? ALCOHOL WITHDRAWAL SEIZURES (1EPISODE AT 1:30AM ON 17/12/22)
TREATMENT GIVEN :
17/12/22
AGE 44
SEX MALE
S
- EPISODE OF SEIZURE ACTIVITY at 1:30 AM
- PASSED STOOLS 2 TIMES
O
PT IS C/C/C
BP- 100/60mm HG
PR -122/min
SPO2 - 93
TEMP - 100 F
CVS - S1 S2 + NOMURMURS
RS - BAE + CREPTS + IN LEFT IAA AND LT.ISA
P/A - SOFT NT
CNS - NFND
A
? CHRONIC LIVER DISEASE SECONDARY TO ALCOHOL
RT.MIDDLE LOBE CONSOLIDATION..? CAP.? TB
WITH ANEMIA UNDER EVALUATION.
P
O2 INHALATION if O2 sat <90%
INJ AUGMENTIN 1.2g IV BD
INJ PAN 40 MG PO OD
INJ THIAMINE 200mg IN 100ML NS IV BD
OVER 30MIN
INJ OPTINEURON 1 AMP IN 100ML NS IV OD OVER 30MIN
TAB HEPAMERZ 500mg PO BD
TAB UDILIV 300mg PO BD
TAB PCM650 MG PO SOS
SYP APTIVATE 15ml PO BD
SYP POTCHLOR 10ml in 1 GLASS OF WATER PO TID
BP MONITORING 2nd HRLY AND VITALS 4rth HRLY
18/12/22
ICU BED NO 2
AGE 44
SEX MALE
S
NO FEVER SPIKES
SLEEP NORMAL
APPETITE IMPROVED
STOOLS PASSED
O
PT IS C/C/C
BP- 100/70mm HG
PR -109/min
SPO2 - 95 on ra
TEMP - 98F
GRBS: 114mg/dl
CVS - S1 S2 + NOMURMURS,JVP NOT RAISED
RS - BAE + CREPTS + IN LEFT IAA AND LT.ISA
OTHER AREAS- NVBS HEARD
P/A - SOFT NT,LIVER SPAN 9cm ON PERCUSSION TYMPANIC NOTE HEARD ,NO DULLNESS,BS +
CNS - HMF INTACT
FINE TREMORS PRESENT
SENSORY RT. LT
PROPRIOCEPTION. UL,LL. +. +
VIBRATION UL,LL. +. +
TOUCH UL,LL. +. +
PRESSURE UL,LL. +. +
REFLEXES B. T. S. K. A. PLANTAR
RT ++. ++. +. ++. +. F
LT ++. ++. +. ++. +. F.
RHOMBERG POSITIVE
GAIT NORMAL
CEREBELLAR SIGNS
DYSDIADOKINESIA ABSENT
HEEL KNEE -
INPUT -1650ML OUTPUT - 600ML
A
? ALCOHOLIC LIVER DISEASE
BILATERAL MIDDLE LOBE CONSOLIDATION..? CAP.? TB
BICYTOPENIA WITH ANEMIA UNDER EVALUATION. ? B12 DEFECIENCY SECONDARY TO ALCOHOL
WITH? ALCOHOL WITHDRAWAL SEIZURES (1EPISODE AT 1:30AM ON 17/12/22)
P
2 EGG WHITES
O2 INHALATION if O2 sat <90%
(D3)INJ AUGMENTIN 1.2g IV BD
INJ PAN 40 MG PO OD
(D2)INJ THIAMINE 200mg IN 100ML NS IV BD
OVER 30MIN
(D1)INJ VIT B12 1500MICROGM IN 100ML NS IV OD
TAB FOLIC ACID 1MG PO OD
TAB UDILIV 300mg PO BD
TAB PCM650 MG PO SOS
SYP GRILLINCTUS 15ML PO TID
SYP APTIVATE 15ml PO BD
SYP POTCHLOR 10ml in 1 GLASS OF WATER PO TID
INJ VIT K 1AMP +100ML NS OVER 10MIN
TAB HEPAMERZ 500 mg PO OD
BP MONITORING 2nd HRLY AND VITALS 4rth HRLY
FOLLOW PSYCHIATRIC ORDERS
T LORAZEPAM 2 MG (1-1-2)
TAB BACLOFEN XL 20MG PO OD HS
TAB BENFOTAMINE 100MG PO OD
ADEQUATE HYDRATION
19/12/22
19/12/22
WARD
AGE 44
SEX MALE
S
NO FEVER SPIKES
SLEEP NORMAL
SOB DECREASED,COUGH REDUCED
STOOLS PASSED ONCE
O
PT IS C/C/C
BP- 120/80mm HG
PR -100/min
SPO2 - 98 on ra
TEMP - 97.3F
GRBS: 120mg/dl
CVS - S1 S2 + NOMURMURS,JVP NOT RAISED
RS - BAE + CREPTS + IN LEFT IAA AND LT.ISA
OTHER AREAS- NVBS HEARD
P/A - SOFT NON TENDER, ON PERCUSSION TYMPANIC NOTE HEARD ,BS +
CNS -
RHOMBERG POSITIVE
GAIT NORMAL
MOTOR UL LL
POWER. RT 5/5. 5/5
LT 5/5. 5/5
TONE. RT . N. N
LT. N. N
INPUT -1200ML OUTPUT - 1150ML
A
1)? ALCOHOLIC LIVER DISEASE
2)WITH RIGHT MIDDLE LOBE CONSOLIDATION..? CAP.? TB
3) WITH BICYTOPENIA UNDER EVALUATION.
4)WITH? ALCOHOL WITHDRAWAL SEIZURES (1EPISODE AT 1:30AM ON 17/12/22)(RESOLVED)
P
2 EGG WHITES
(D4)INJ AUGMENTIN 1.2g IV BD
(D2)INJ VIT B12 1500MICROGM IN 100ML NS IV OD
SYP POTCHLOR 20ml in 1 GLASS OF WATER PO TID
(D2)INJ VIT K 1AMP +100ML NS OVER 30MIN
T OROFER XT PO BD
T LORAZEPAM 2 MG (X-X-2)
TAB BACLOFEN XL 20MG PO OD HS
TAB BENFOMET 100MG PO OD( X-1-X)
20/12/22
WARD
AGE 44
SEX MALE
S
NO FEVER SPIKES
SLEEP NORMAL
SOB DECREASED,COUGH REDUCED
STOOLS PASSED ONCE
O
PT IS C/C/C
BP- 90/60mm HG
PR -100/min
SPO2 - 96% on ra
TEMP - 97.3F
CVS - S1 S2 + NOMURMURS,JVP NOT RAISED
RS - BAE + , CREPTS + IN LEFT IAA AND LT.ISA
INFRA MAMMARY AREA
OTHER AREAS- NVBS HEARD
P/A - SOFT NON TENDER, ON PERCUSSION TYMPANIC NOTE HEARD ,BS +
CNS -
RHOMBERG POSITIVE
GAIT NORMAL
MOTOR UL LL
POWER. RT 5/5. 5/5
LT 5/5. 5/5
TONE. RT. N. N
LT. N. N
A
1)? ALCOHOLIC LIVER DISEASE
2)WITH RIGHT MIDDLE LOBE CONSOLIDATION..? CAP.? TB
3) WITH BICYTOPENIA SECONDARY TO FOLIC ACID DEFECIENCY
4)WITH? ALCOHOL WITHDRAWAL SEIZURES (1EPISODE AT 1:30AM ON 17/12/22)(RESOLVED)
P
2 EGG WHITES
(D5)INJ AUGMENTIN 1.2g IV BD
(D3)INJ VIT B12 1500MICROGM IN 100ML NS IV OD
SYP GRYLLINCTUS 15MLPO TID
(D3)INJ VIT K 1AMP +100ML NS OVER 30MIN
T OROFER XT PO BD
T LORAZEPAM 2 MG (X-X-2)
(D4)TAB BACLOFEN XL 20MG PO OD HS
TAB BENFOMET 100MG PO OD( X-1-X)
21/12/22
WARD
AGE 44
SEX MALE
S
NO FEVER SPIKES
SLEEP NORMAL
NO SOB ,NO COUGH
STOOLS NOT PASSED
O
PT IS C/C/C
BP- 90/60mm HG
PR -80bpm
SPO2 - 96% on ra
TEMP - 97.3F
RS - BAE + , IAA,ISA, MAMMARY CREPTS PRESENT
OTHER AREAS NVBS
CVS - S1 S2 + NOMURMURS,JVP NOT RAISED
P/A - SOFT NON TENDER, ON PERCUSSION TYMPANIC NOTE HEARD ,BS + 9/min
CNS -
RHOMBERG NEGATIVE
GAIT NORMAL
MOTOR UL LL
POWER. RT 5/5. 5/5
LT 5/5. 5/5
TONE RT N N
LT N N
A
1)? ALCOHOLIC LIVER DISEASE
2)WITH RIGHT MIDDLE LOBE CONSOLIDATION..? CAP.? TB
3) WITH BICYTOPENIA SECONDARY TO FOLIC ACID DEFECIENCY
4)WITH? ALCOHOL WITHDRAWAL SEIZURES (1EPISODE AT 1:30AM ON 17/12/22)(RESOLVED)
P
2 EGG WHITES
(D3)INJ VIT B12 1500MICROGM IN 100ML NS IV OD
SYP GRYLLINCTUS 15MLPO OD
T OROFER XT PO BD
T LORAZEPAM 2 MG (1/2-X-2)
(D5)TAB BACLOFEN XL 20MG PO OD HS
TAB BENFOMET 100MG PO OD( X-1-X
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