A Case of 64yrs old male patient with obstructive jaundice

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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 in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. 

A 64 year old man resident of bengal, is a farmer by occupation came with the complaints of yellowish discolortion of eyes  since 1 month.

HISTORY OF PRESENT ILLNESS

History of low grade fever, intermittent, not associated with chills and rigor.

Patient also complaints of yellowish discoloration of urine since 1 month, passing of clay colored stools since 1 month.

He also complaints of itching all over the body since 1 month, decreased appetite, loss of weight and generalised weakness since 1 month.

Patient has pain in both knees since 6 months. 

HISTORY OF PAST ILLNESS 

No similar complaints in past.

No h/o diabetes 

No h/o hypertension 

PERSONAL HISTORY 

Diet -mixed 

Appetite - lost 

Bowel- regular 

Sleep -adequate

Addictions- no addictions

FAMILY HISTORY 

no family history 

TREATMENT HISTORY 

Patient had back pain in january for which he got treated at the local hospital in bengal. Pain relieved after taking medications.

GENERAL EXAMINATION 

Patient is consicous,cohorent,well oriented towards time place and person.

Pallor - absent 

Icterus-present 

 

Clubbing-absent 

Cyanosis-absent 

Lymphadenopathy - absent 

Edema-absent

VITALS 

Temperature-afebrile 

Pulse rate -92 

Respiratory rate- 22 bpm

Bp-100/60 

SYSTEMIC EXAMINATION 

CVS - S1 S2 (+)

Respiratory rate - BAE(+), NVBS (+)

Abdomen-

scaphoid ,

no tenderness,

no palpable mass,

Liver not palpable 

Spleen not palpable 

Bowel sounds -yes 

CENTRAL NERVOUS SYSTEM  

Patient is conscious with  higher functions intact 

REFLEXES  

                              RIGHT.                       LEFT.   

BICEPS                    +2                              +2

TRICEPS                  +2                               +2

SUPINATOR            +2                                +2

KNEE.                      +2                                 +2

ANKLE.                   +2                                 + 2

INVESTIGATIONS 

DIAGNOSIS: OBSTRUCTIVE JAUNDICE

TREATMENT  

1)Tab Zincovit 

2)Tab levocitrizine 10mg

3)Tab pregabalin 75mg

4)syp Lactulose 10ml