A 42 year old male with body pains and fever

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I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan

Chandana racha

Roll no 128

Chief complaints:- fever since 6 days

                               vomitings on and off since 4 days

                                 Shortness of breath since 2 days

                              Yellowish discoloration of urine since 1 day

A 42 year old male, farmer by occupation, came to the OPD 9 days ago with complaints of fever, body pains, yellowish discoloration of the eyes and vomiting since the previous day.

    The patient was apparently asymptomatic  17 days ago. He then had decreased appetite for a week before he developed fever, body pains, yellowish discolouration of sclera and vomitings. He then got admitted to this hospital.

HISTORY OF PRESENT ILLNESS:-

 The patient has had a habit of drinking alcohol around 3 times a week since many years.

2 years ago, the patient's wife passed away, which increased the amount of drinking.

17 days ago, the patient started having a decreased appetite because of his drinking habits.

 10 days ago, the patient went to work to spray pesticides in the field as a part of his work. In the evening, the patient drank 90ml of alcohol and lost his appetite completely, associated with fullness of abdomen. He felt body pains and was found to have a fever,which was intermittent with medication. He also vomited. The vomit consisted of dal from his lunch. He didn't eat anything else that night.

The next day (9 days ago), he was taken to an RMP, who took his blood sample. It was found that his blood cell counts were low. He was then taken to another government hospital, where the doctors told him that his liver was damaged by his alcohol consumption. He was also told his kidney is not actively functioning and need for dialysis and then given glucose and referred to this hospital. He had hypochondrial pain with tenderness. He also had pruritus and fullness in his abdomen.

2-3 days after admission (7 days ago), the patient developed generalised swelling all over the body with body pains and tenderness in the hypochondrial region. He also didn't eat anything for these 2-3 days and was on fluids.

3 days ago, the patient's swelling and body pains got relieved with the medication, including the hypochondrial pain.

He underwent dialysis for 3 times in a week

There is no history of burning Micturition, loose stools. No history of cough, itching, rashes

 .HISTORY OF PAST ILLNESS:-

No similar complaints in the past.Not a known case of diabetes, hypertension, CAD, CVA, asthma, tuberculosis, epilepsy. History of rodent exposure. 

Treatment history:- not significant     

    PERSONAL HISTORY:-

Diet: mixed

Appetite: decreased

Bowel movement: regular

Micturition: normal but yellowish discoloration since 1 day. 

Addictions: alcohol consumption around 3 times a week since many years 

FAMILY HISTORY:-

Not significant   

PHYSICAL EXAMINATION:-

 General examination:-patient is examined in supine position with his consent in well illuminated area.

(At the time of admission)

 The patient is conscious, coherent and cooperative.

  He is well built and moderately nourished.

Pallor - absent

Icterus - present

No clubbing, cyanosis, lymphadenopathy, pedal edema

Patient is mildly dehydrated

Pedal edema was present on admission

Vitals:-

Temperature: 99 F

Pulse rate:100 bpm

Respiratory rate: 22 breaths/min

Blood pressure: 110/80mmHg

SPO2: 97%

GRBS: 126mg% 

SYSTEMIC EXAMINATION:-

Abdomen:-

Inspection:- shape of abdomen:- distended.All quadrants move with respiration, umbilicus is inverted, no engorged veins, no visible pulsations, no scars and sinuses present. 

Palpation:- no local rise of temperature, localized pain over right Hypochondrium,shifting dullness was present. Kidneys are ballotable. 

Percussion :- 

CNS:-

The patient was conscious, coherent cooperative and .