A 55 year old female with yellowish discoloration of eyes

 Hi, This is G. Nandini a fifth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them. 
 
DOA:18/07/2022

A 55 year old female  agricultural worker by occupation (stopped 2 years ago) came with cheif complaints of yellowish discolouration of eyes and body , Fever and generalized weakness since 20 days . 

 HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 20 days back and developed fever associated with burning Micturtion and they also noticed yellowish discolouration of eyes and skin and bought her to our hospital . She was diagnosed with jaundice here and advised for admission patients attendents doesn't want to get admitted. They used some herbal medication every Monday by skipping Antihypertensive and anti diabetic medication  for 2 weeks but it didn't subside and Then she was fine until yesterday night and slept having dinner. Then she wake up at 2:00 AM for urination but she has difficulty in passing urine and couldn't pass urine. So she slept again and woke up at 5:00 AM and started developing sweating and weakness.  they again came to our hospital because from morning 6:00 am she spoke irreverent things. 

PAST HISTORY:

k/c/o Diabetes  and hypertension since 6 years

Not k/c/o asthma, tuberculosis, epilepsy

No previous surgeries and blood transfusions. 
 


PERSONAL HISTORY:

He is married. 

 Mixed diet. 

Appetite :Normal

Micturtion: Burning Micturtion

Bowel : irregular

 bladder habits : abnormal

Occasionally drinks alcohol and stopped tobbaco chewing 20 days back and she had a habit of drinking toddy (stopped 6 years back) 

FAMILY HISTORY:

Has no family h/o  HTN, TB, heart disease,cancers, epilepsy. 

Family h/o of DM (father) 

GENERAL EXAMINATION : 

Vitals :

• BP - 140/90 mmHg

• Temp. - 98°F

• SpO2 - 99%

• RR - 18 cycles/min

• PR - 84 bpm

•GRBS : 54 mg%

PALLOR : Absent

ICTERUS : present

CYANOSIS :Absent

CLUBBING :Absent
 
GENERALIZED LYMPADENOPATHY :Absent

ODEMA :Absent

DRUG HISTORY:

For HTN: Tab. AMLONG 5 mg PO/OD

For DM: Tab. METFORMIN 500mg.,Tab. GLIMIPIRIDE 

  
SYSTEMIC EXAMINATION :


CVS:

• S1, S2 heard

• No thrills and cardiac murmurs

RESPIRATORY SYSTEM:

• No dyspnoea, wheezing

• Postion of trachea - central

• Breath sounds - Vesicular

ABDOMEN:

• No tenderness, palpable mass, bruits

• No palpable liver and spleen

•Shape :obese

CNS:

• Conscious and coherent

• Speech - normal 

No signs of meningeal irritation

• Glass gow coma scale - 15/15

PROVISIONAL DIAGNOSIS: Jaundice



INVESTIGATIONS:

On 1/7/2022










On 18/07/2022
2D Echo

ECG

Ultrasound
 clinical images:
19/07/2022
23/07/2022

Treatment

On 18/07/2022
IVF-DNS 50ml
INJ- PANTOP 40 mg IV/OD
INJ. ZOFER 4 mg IV
TAB. UDILIV 300 mg PO/BD
Tab. WYSOLONE 10mg
Syp. LACTULOSE 25 ml PO

On 19/07/2022

INJ- PANTOP 40 mg IV/OD
INJ. ZOFER 4 mg IV
TAB. UDILIV 300 mg PO/BD
Tab. WYSOLONE 10mg
Syp. LACTULOSE 25 ml 
INJ. NEOMOL 1gm  IV/BDS
TAB. RIFAGUT 550 mg Po/BD

On 20/07/2022

INJ- PANTOP 40 mg IV/OD
INJ. ZOFER 4 mg IV
Syp. LACTULOSE 25 ml 
INJ. NEOMOL 1gm  IV/BDS
TAB. RIFAGUT 550 mg Po/BD
TAB. PCM 500 mg PO/BD
INJ. TRENEXA 500 mg IV/STAT
SYP. AROSTROZYME 25ml PO/TID 

On 21/07/202

On 22/07/2022

On 23/07/2022


On 24/07/2022


On 25/07/2022
On 26/07/2022

On 27/07/2022

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