A 55year old male came with yellow discolouration of eyes and fever

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A 55 year old male from valligonda , tile and granite fixer by occupation came to OPD 

Chief complaints:-  yellowish discolouration of eyes since 1 month.

HOPI :-
Patient was apparently asymptomatic 3 months back then he developed abdominal pain , sudden in onset, gradually progressive, intermittent , throbbing type pain , in the right hypochondrium region and epigastric region, it is non- radiating. There were no aggravating factors and was relieved on taking medication , which was given to him by a local pharmacist.( unknown medication)

2 months back he developed low grade fever, sudden in onset, continuous and associated with chills and rigour. It was relieved on taking medication. ( dolo )

One month back he developed yellowish discolouration of the eye, insidious in onset, gradually progressive and increased in intensity over past one week. He consumed ayurvedic medicine weekly once for one month but it didn’t give him relief.

( according to his mother she felt his eyes were yellow and she performed an old ritual which is followed in her village and confirmed that he might be having jaundice and brought him some ayurvedic medicine).

History of decreased appetite and weight loss since 1 month.

History of itching over the legs since 1 month , which was increased in the evenings and night.

No history of loose stools, clay coloured stools, nausea, vomiting, headache, dizziness, burning micturition, low urine output.

No history of haematemesis, malaena, constipation, abdominal distension.

No history of breathlessness, cough.

PAST HISTORY:-

-History of TB 35 years back where he took medication for 3 months only.

-Appendectomy 25 years back.

-RTA - 6 years back, where had a right knee fracture which was treated outside.

Not a know case of DM, HTN, asthma, epilepsy, CVA, CAD.

PERSONAL HISTORY:- 

diet- mixed

Appetite is decreased 

bowl and bladder movements- regular 

Sleep- inadequate 

Addictions- quarter alcohol daily from past 35 years and stopped taking alcohol from past 2 month 

- consumes tobacco daily [ one pack per day ]. 

.

DAILY ROUTINE:-

Wakes up a 5am and extracts the milk from cows and distributes it.

At 7am, he freshens up and drinks tea 

At 9am , eats breakfast ( rice with vegetable curry) and goes to work.

He works at construction site as tile and granite fixer.

At 2pm, he consumes his lunch ( again rice curry) and continues to work.

He returns home by 7pm and brings alcohol while coming back.

8 to 9pm , he drinks alcohol and eats dinner.

He stopped consuming alcohol from past 2 months. 

Usually sleeps by 10 pm but is having trouble in sleeping for past 2 weeks.

FAMILY HISTORY:- not significant 

ON EXAMINATION 

GENERAL EXAMINATION:-

Patient is conscious, coherent and cooperative

Well oriented to time , place and person.

Moderately built and moderately nourished.

Vitals at presentation:

TEMP- 98.6 degrees Celsius 

Pulse - 96 bpm regular normal volume 

BP- 110/ 70 mmHg

RR- 18 cycles per minute.

Presence of icterus.

No pallor, clubbing, Cyanosis, lymphadenopathy, oedema.

SYSTEMIC EXAMINATION:

1) PER ABDOMEN:

INSPECTION:

-Shape of abdomen: flat 

-Umbilicus: inverted

-Presence of appendectomy scar

-All quadrants are moving equally with respiration

-No engorged veins

- skin over the abdomen is smooth 

-Hernial orifices intact

PALPATION:

-No local rise of temperature 

- diffuse tenderness over the abdomen 

-No Rebound tenderness 

-No guarding rigidity

- liver not palpable 

- spleen not palpable 

Abdominal girth: 89 cm

PERCUSSION:

Shifting dullness - absent 

No fluid thrill

Liver span - 9 cm

Liver dullness is not heard at 5th intercostal space.

AUSCULTATION:

On 12th Bowel sounds not heard 

Today- diminished bowel sounds 

2) CARDIOVASCULAR:

Inspection: 

apex beat :5th ICS half inch medial to midclavicular line

Palpation:

inspectory findings confirmed, No thrills or parasternal heave

Auscultation: S1 , S2 heard and no murmurs 

3) RESPIRATORY SYSTEM:

INSPECTION:

Shape of chest:Bilaterally symmetrical, Elliptical in shape

No visible chest deformities

No kyphoscoliosis,

Abdomino thoracic respiration, No irregular respiration

No tracheal shift

No dropping of shoulders, Spino scapular distance appears equal on both sides 

no sinuses and scars

No engorged veins

PALPATION

Inspectory findings confirmed by Palpation

Chest movements - normal

Chest expansion-equal on both sides

PERCUSSION:

Resonant note heard over all areas

AUSCULTATION:

- coarse crepitations heard at right infra clavicular and  right mammary areas.

- Norma vesicular breath sounds heard in all other areas.

-Vocal resonance: normal in all areas

4) CNS:

Higher mental functions :intact

Cranial nerves intact

Motor examination:      R               L

 

Bulk.                              N               N

Tone.                              N               N

Power.                            N               N

Reflexes:

Biceps.                         2+              2+

Triceps.                        2+              2+

Supinator                     2+.             2+

Knee                             2+              2+

Ankle.                           2+.             2+

Sensory examination:Normal

No meningeal signs

PROVISIONAL DIAGNOSIS:-  

DenovoHIV positive 

Alcoholic liver disease?

Drug induced liver injury?

INVESTIGATIONS:-