A 42 year old male with body pains and fever

October 06, 2022

Welcome to my blog! I am Varshitha Kalidindi, a 2nd year medical student. This is an e-log to discuss our patient's de-identified health data after taking informed consent of the patient. It also reflects patient centered online learning portfolio.

I will be looking forward to some feedback and valuable inputs through the comments box provided below.

I have been given this case 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, diagnosis and treatment plan.

CASE:-

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 (patient can't remember since when).

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. He ate his food normally that day and had dal for lunch. 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 given glucose and then 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 the first time yesterday.

HISTORY OF PAST ILLNESS:-

Not a known case of diabetes, hypertension, CAD, CVA, asthma, tuberculosis, epilepsy

TREATMENT HISTORY:-

Not significant

PERSONAL HISTORY:-

Diet: mixed

Appetite: decreased

Bowel movement: regular

Micturition: normal

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