57 yrs female with obstructive jaundice

 57 YEAR OLD WAS PRESENTED RO OPD WITH YELLOW ISH DISCOLORATION OF SKIN,CONJUNTIVA, ABDOMINAL PAIN.

July 30, 2023

This is an online e log book to discuss our patient health data shared after taking his/her/guardians singned informed consent. Here we discuss our individual patients problems with an aim to solve the patient’s clinical problem with collective current best evident based input.

This E blog also reflects my patient cantered 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.

This is a case of 57 year old female , housewife staying in Mathavanga , West Bengal.

CHIEF COMPLAINTS:

- pain in abdomen since 3 1/2 months 

- tingling pain in the abdomen   

- can't stand / sit without support  

- iching all over the body  (since 1month)

- generalized weakness 

- yellowish discoloration of sclera and skin and stools ( since 25 days ).

HISTORY OF PRESENTING ILLNESS: 

Patient was apparently asymptomatic 2months back then she noticed yellowish discoloration of eyes and urine and went to hospital and on further evaluation she was diagnosed to have type 2 diabetes mellitus and was started tab.dapgliflozin 10mg in the morning and tab.sitagaliptin 50mg + t.metformin 500mg at night.

C/o pain over the periumbilical region since 2months ,pricking type of pain ,non radiating,no aggrevating and relieving factors.(slight Decrease in pain from last 2days 

H/o occasional tingling and numbness of upper limb and lower limb.

No c/o polyphagia,polydypsia,nocturia.

Past history -

In 2010, she had difficulty in breathing during winter season and monsoons (? Bronchial Asthma ) and used tab.deriphylline 450mg 1/2 tab PO/BD for 5-7days during the attacks along with inhaler ,presently she is not having any difficulty and not using.

K/c/o diabetes mellitus 2months and on tab.dapgliflozin 10mg in the morning and tab.sitagaliptin 50mg + t.metformin 500mg at night.

Dietary history -

She consumes

 tea along chapathi in the morning

Sometimes chole (boiled and mashed )

Afternoon - rice and dal along with some vegetables.

In between biscuits as snacks

And chapathi at night.

 Personal history

Normal - appetite

Adequate -sleep

Regular bowl movements

Normal bladder movements

No history of alcohol, smoking and chewing of tobacco .

FAMILY HISTORY:

No significant family history.

General examination:

Patient is conscious, coherent and cooperative and well oriented to time place and person. 

Pallor present.

Icterus: present 

No clubbing,cyanosis,lymphadenopathy,odema.

Vitals -

Bp - 110/70mm hg

Pulse rate - 86bpm

RR-16cpm 

Grbs -162mg/dl

SYSTEMIC EXAMINATION:

CVS: 

S1 and S2 heard. 

No addded thrills or murmurs heard

RESPIRATORY SYSTEM:  

Normal vesicular breath sounds heard. 

Bilateral air entry present.

Abdomen:

INSPECTION:

shape of abdomen - schaphoid.

umbilicus -central

no sinuses

No scars

PALPATION:

Tenderness present over   right  hypochondriac region.

PERCUSSION:

No shifting dullness

AUSCULTATION:

Bowel sounds  present 

CNS:

Conscious and coherent.

Normal sensory and motor responses

FAMILY HISTORY:

No significant family history.

INVESTIGATIONS:

21/7/23

Treatment:

1.TAB ZOFER 4 MG PO/BD

2.TAB PAN 40 MG PO/OD BFF

3. TAB. DAPAGLIFOZIN 10mg PO/OD

4. TAB SITAGLIPTIN 50 MG +TAB METFORMIN 500 MB PO/TOD .

 5. GRBS MONITORING

22/7/23:

Surgery refferal was taken 

After examining patient they adviced for ERCP for pancreatic duct stenting with or without biopsy and to continue same treatment.

23/7/23:

Patient complaints of periumblical region pain and generalised pruritis due to which she's having difficulty in sleeping .

Tab ultracet 1/2 tab qid

And t.cetrizine po/bd have been added.

On 24/7/23

29/7/23:

7AM:67 mg/dl

Patient complaints of not passing stools since yesterday evening,proctolytic enema was given at 7:30 pm.

29/7/23:

Gastroreferral taken advised for follow up after 5days  they adviced USG abdomen and LFT.

31/7/2023:

patient complaints of nausea and pain in right hypochondrium.

Treatment:

1.Tab Zofer 4 mg PO/TID

2.Tab ultracet 1/2 tab PO/QID

3.TAB Avil 25 mg PO/QID

4.TAB Pan 40 MG PO/OD

5.GRBS monitoring

1/8/2023:

 

patient complaints of pain in umbilical region and right hypochondriac region

Vitals:

BP: 100/60 mmhg

PR:78 BPM

RR: 15 cpm

Temperature:97.2 F

Treatment:

1.Tab Zofer 4 mg PO/TID

2.Tab ultracet 1/2 tab PO/QID

3.TAB Avil 2 mg PO/QID

4.TAB Pan 40 MG PO/OD

5.GRBS monitoring

3/8/23:

Patient has been taken to khl for EUS and FNAB.

5/8/23:

patients complaint of generalised pruritis has not decreased and due to which she has not been able sleep yesterday.

Vitals:

BP: 120/60 mmhg

PR:78 BPM

RR: 16 cpm

1.Tab Zofer 4 mg PO/TID

2.Tab ultracet 1/2 tab PO/QID

3.TAB Avil 2 mg PO/QID

4.TAB Pan 40 MG PO/OD

5.GRBS monitoring

Derma refferal was taken I/v/o pruitits and has been advised to take 

1.VENUSIA MAX LOTION FOR LA/BD/2 weeks.