A case of 64yrs old male patient with obstruction 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 64 year old man resident of bengal, is a farmer by occupation came with the complaints of yellowish discoloration of eyes  since 1 month.

HISTORY OF PRESENT ILLNESS

•History of low grade fever, intermittent, not associated with chills and rigor.

•Patient also complaints of yellowish discoloration of urine since 1 month, passing of clay coloured stools since 1 month.

•He also complaints of itching all over the body since 1 month, decreased appetite, loss of weight and generalised weakness since 1 month.

•Patient has pain in both knees since 6 months. 

HISTORY OF PAST ILLNESS 

.No similar complaints in past

.No h/o diabetes 

.No h/o hypertension 

PERSONAL HISTORY 

-Diet -mixed 

-Appetite - lost 

-Bowel- regular 

-Sleep -adequate

-Addictions- no addictions

FAMILY HISTORY 

*No family history 

TREATMENT HISTORY 

•Patient had back pain in january for then he got treated at the local hospital in bengal. Pain relieved after taking medications.

GENERAL EXAMINATION 

*Patient is conscious,coherent,well oriented 

towards time place and person.

*Pallor - absent 

*Icterus -present 

 


*Clubbing -absent 

*Cyanosis -absent  

*Lymphadenopathy - absent 

*Edema-absent

VITALS 

•Temperature -afebrile 

•Pulse rate -92 

•Respiratory rate- 22 bpm

•Bp -100/60 

SYSTEMIC EXAMINATION 

-CVS - S1 S2 (+)

-Respiratory rate - BAE(+), NVBS (+)

-Abdomen-

-scaphoid ,

-no tenderness,

-no palpable mass,

-Liver not palpable 

-Spleen not palpable 

-Bowel sounds -yes 

CENTRAL NERVOUS SYSTEM  

*Patient is conscious with  higher functions intact 

REFLEXES  

                              RIGHT                      LEFT   

BICEPS                    +2                              +2

TRICEPS                  +2                               +2

SUPINATOR            +2                               +2

KNEE                       +2                               +2

ANKLE                   + 2                                +2 


INVESTIGATIONS




  

DIAGNOSIS : OBSTRUCTION JAUNDICE

TREATMENT 

  • Antibiotic therapy (if indicated for infection)
  • Endoscopic retrograde cholangiopancreatography (ERCP), 
  • Intravenous fluids and pain medications

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