40 YR OLD MALE WITH YELLOWISH DISCOLORATION OF SCLERA.

This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 


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 histoty, clinical findings, .investigations and come up with a diagnosis and treatment plan. 

A 40 year old male who is a coconut vender came to casualty on 9/10/2022 with  :
• constipation since 10 days
• Yellowish discoloration of sclera and urine from 3 days.
• cough(dry cough) since 2 days.
• throat pain since 2 days.
HOPI: 
Patient was apparently asymptomatic 3 years ago then he was diagnosed with hypertension since then he is on amplodipine , metaprolol , telma , clonidine.
9/8/2022- 
 He came to casualty with :
• constipation since 10 days
• Yellowish discoloration of sclera and urine from 3 days.
• cough(dry cough) since 2 days.
• throat pain since 2 days.
PERSONAL HISTORY: 
He is an alcoholic since 35 years  last binge 10 days ago.
• He is an occasional smoker.
GENERAL EXAMINATION: 
Pt is conscious, coherent, cooperative
Bp-120/80 mmHg
PR-81bpm
Temp -98.5°F
SpO2- 91%
GRBS -116mg% 
CVS : S1 S2 +, Apex beat : 5th ICS mid clavicular line.

RS : BAE +, No crepts 

CNS : NAD

P/A : Soft, no tenderness . Bowel sounds +
No pallor cyanosis, clubbing or lymphadenopathy.
INVESTIGATIONS;
FINAL DIAGNOSIS: 
OBSTRUCTIVE JAUNDICE with HbsAG +

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