A 34 year old male with jaundice and vomiting.

 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. 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.

MANOGYNA RAO BONTHA

ROLL NO 87

• 34 year old male lorry driver by occupation,resident of Chityal,came to OPD with 

CHIEF COMPLAINTS:

• Vomiting since 3 days
• Hiccups since 3 days
• Cough since 3 days
• Loose stools for 1 day,3 days back

HOPI:

patient was apparently asymptomatic 3 months back then he developed yellow discolouration of eyes associated with vomitings 5-6 episodes per day non bilious containing food particals  for which he went to local hospital and diagnosed as jaundice and treated for it.  

Then  3 days back then he had h/o vomiting 10-15 episodes/day sudden in onset,non bilious,non projectile,food and water as the contents 

 

Vomiting is present immediately after food water and alcohol intake

Associated with generalised weakness 

Loose stools- 4 episodes lasted for 1 day 3 days back

Non blood stained,large volume not associated with pain abdomen and fever, black coloured stools 

 

Hiccups Since 3 days continuously, associated with mild difficulty in swallowing 

 

Cough- dry since 3 days not associated with fever sore throat cold. 

PROVISIONAL DIAGNOSIS:

Alcoholic liver disease ?

Acute pancreatitis?

Hyponatremia with hiccups 

Prerenal AKI

TREATMENT:

 IVF-0.9% NS @ 100 ml / hr

RL@100 ml/ hr

Inj. Pantop 40 mg I/v Od 

Tab baclofen 10 mg

Inj zofer 4 mg Iv TID

Inj thiamine.

Inj metoclopromide

Syp lactulose

Strict I/o charting