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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT


A 42-year-old male patient who is a carpenter came to the casualty with the CC of Hiccups 4 days back and Pain abdomen and vomitings 3 days  back.

HOPI-

The Patient was apparently asymptomatic two years back then he had yellow discoloration of the sclera for which he visited a nearby hospital and got treated conservatively.

 Then one year back, he again had yellow discoloration of sclera, for which the patient took medication.

Eleven days back, the Patient had an injury to the ring finger of right hand. Then there was swelling of the right hand.

He had fever 7 days back associated with chills and rigor, not associated with evening rise of temperature and got treated with PIPTAZ .

10 days back he was suffering from continuous hiccups and got relieved temporarily from drinking water and the hiccups continued as soon as he vomited water. Followed by Abdominal pain.

18-20 episodes of vomitings in two days which were non-bilious non-projectile, food and water as contents. 

Past history:-

DM(5 years back)

not a known case of HTN, Epilesy, asthma, TB, leprosy 

Personal history:- 

appetite - normal

diet - mixed

bowel and bladder - regular

sleep adequate - adequate

addictions - alcohol 

Family History:

not significant

General Examination:

the patient is conscious co-operative and well oriented to time place and person.

well built and well nourished

Vitals

temperature:-Afebrile

pulse rate:- 80 bpm

respiratory rate:-20 CPM

B.P:-120/90 mm Hg

SPO2:- 99%

Pallor - No 

Icterus - present

Cyanosis - No

Clubbing - No

Lymphadenopathy - No

Edema - No 

Systemic Examination 

Abdomen-

mild distension

Tenderness - present

Liver and spleen not palpable

Bowel sounds - Normal

Respiratory System : 

BAE - +

NVBS

Cardiovascular System:

S1, S2 - Heard 

No murmurs

CNS- NAD

Clinical Images 

 




Investigations -









DIAGNOSIS:-

Leptospirosis with AKI, DM for 5 years


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