57 Year old Male

 This is an online E log book to discuss our patient's de-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 patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box

A 57 YEAR OLD MALE mechanic by occupation resident of Nalgonda

Chief complaints:

Constipation since 20 days 

Fever since 5 days

History of presenting illness:

 Patient came with complaint of constipation since 20 days for which he was admitted in hospital for three days 

Hiccups 15 days back admitted in hospital for three days

Body pains

Decreased appetite since 4-5 days

Fever since 5 days  evening rise

Complaint of giddiness 3-5 episodes in last 1 year

 No history of decreased urine output vomiting headache

 

History of past illness :

History of giddiness- Accident 1 year back

Known case of Hypertension since 1 and half year

1month back giddiness and left sided paralysis, admitted to hospital

Not a known case of Diabetes mellitus TB epilepsy CAD asthma

Personal history :

appetite - lost

 diet - mixed

 bowels  - constipation 

micturition - normal 

no known allergies 

addictions :

 Smoker since 30 years 6cigaretts per day, BD 25 per day stopped since 15days

Alcoholic since 25 years, drinks beer and whiskey. Stopped since one month

Family history : no significant family history

General examination :

Patient is conscious, coherent and cooperative .

Well built and nourished

No Pallor ,icterus, cyanosis, clubbing,lymphadenopathy, Edema.

Vitals:

Temperature -afebrile

 Pulse rate- 84 bpm

BP-110/70mmHg

SPO2-94%

 GRBS- 124mg /dl

Per Abdomen:

Scaphoid, soft Tender in right iliac fossa

Bowel sounds heard

Cardiovascular system :

S1 S2 heard 

no cardiac Murmurs

Respirator system :

 Trachea position Central 

Vesicular breath sounds

CNS:

No focal and neurological deficits

USG:

Mild hepatomegaly,  Grade 1 Fatty liver

ECG

Investigations

X-ray 

Electrophoresis :

Polyclonal gammopathy

Diagnosis:

Hypoactive delerium secondary to Hepatic encephalopathy

Alcoholic Liver Disease

Acute Kidney Injury

Hypercalcemia

Hyponatremia

Hypoalbuminemia

Hiccups

Polyclonal gammopathy