55M with DM2 ,JAUNDICE,LEPROSY
Balu
IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE 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
Chief complaints:-
Fever since 15 days
Yellowish discoloration of eyes and skin since 15 days
The male resident of Nagarjuna Sagar, born and raised in the same town, attended school until the 3rd standard but discontinued due to a lack of interest in studies. He started working at a young age, assisting his parents in caring for his siblings and taking on responsibilities as the elder son, contributing to the family even after discontinuing his education.
The entire town, where all residents are relatives, used to celebrate Dasara grandly. However, this festive tradition was interrupted when the patient was hospitalized, creating a somber atmosphere for his family and cousins.
Twenty years ago, the patient earned a living by selling alcohol produced at home by his wife. Concurrently, he developed a drinking habit. With the income generated from alcohol sales, he invested in green fields and transitioned to farming, a venture he has been involved in for the past 10 years.
A year ago, he noticed a painless, non-itching hypopigmented lesion on his left wrist. Despite being diagnosed with leprosy and recommended treatment by a doctor, he initially neglected it as the lesion caused no discomfort. Over time, as the lesion expanded, he sought medical attention again and commenced Dapsone treatment. Two weeks into the treatment, he experienced fever and yellowish discoloration of the eyes.
Fifteen days ago, he developed insidious, low-grade fever with associated chills and rigors, lasting a week and relieved with medication. Subsequently, he observed yellowish discoloration of urine and eyes.
He reported a one-day history of non-productive, dry cough. No associated symptoms like sore throat, palpitations, shortness of breath, decreased urine output, chest pain, hematuria, bleeding gums, rectal bleeding, loose stools, vomiting, or abdominal pain were reported. Two days ago, the patient noted pedal edema of the pitting type, coinciding with a sedentary period of five days.
CLINICAL IMAGES:-
Past history in brief:-
K/c/o Diabetis mellitus II since 6 years, on unknown medication
N/k/c/o HTN, BA ,CVA , CAD , TB, Epilepsy
H/O Leprosy ? Hypopigmented patches 1year ago.
PERSONAL HISTORY
Married
Mixed diet
Decreased Appetite
Regular Bowel and bladder
No allergies
Alcoholic since 20 years, stopped one year ago.
FAMILY HISTORY
Not significant
GENERAL EXAMINATION:
Patient is conscious, coherent and co-operative,well oriented to time,place and person.
Moderately build and well nourished.
Examination was done in a well lit room.
Pedal edema + ( grade 2)
Icterus +
No pallor, cyanosis,clubbing,lymphadenopathy
Vitals
PR- 96 bpm
BP- 130/80 mm Hg
RR- 16 cpm
Temp -100 F
GRBS - 144 mg/dl
No organomegaly
INVESTIGATIONS
31/10/23
PROVISIONAL DIAGNOSIS
? Drug induced hepatitis
K/c/o Leprosy
K/c/o DM II
Dapsone syndrome?
With anaemia
TREATMENT
INJ.PIPTAZ 2.25 iv/ TID
INJ. Lactulose 10 mg PO/BD
T. Rifixime 200 mg PO BD
INJ. VIT K 10 mg iv/OD
T. Dolo 650 mg PO/TID
posted by Sri Govardhini @ November 07, 2023
