A 41 year male patient with liver disease

a 41 year old male patient with chronic liver disease 

August 28, 2022


Iam P.Madhuri 3rd semester medical student.this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.
Chief complaint:A 41 years old male patient, farmer by occupation, living in narketpally came to the opd with fever, weakness, body pains, swelling of lower limbs, nausea, vomiting, headache, loose stools.
History of present illness: the patient was apparently asymptomatic 10 years ago, then he was diagnosed with hypertension since then he was on medication.he started consuming alcohol when he was 23 years old, he used to drink 2 large glasses of alcohol, which was gradually increased to 6 large glasses till 9 months back and then he developed weakness, involuntary fine movements more likely as tremors, yellowish discoloration of sclera, and he got admitted here, then through medication the symptoms are manged. 2 years back he felt giddiness and weakness for which he went to rmp and got detected by diabetes, for which he started using medicines but stopped taking after 1week  because the signs of giddiness are present even after diet was normal. He didn't get tested again for the blood glucose levels and there was irregular use of medicines for diabetes.2 days back he got admitted here for weakness and body pains.he had pedal edema since 1 month.
History of past illness:
Hypertension since 10 years 
Diabetes since 2 years
No history of asthma,  tuberculosis, CAD, epilepsy,  thyroid
Personal history:
Normal Appetite 
Adequate diet 
Regular bowel movements 
Adequate sleep
No known allergies 
Chronic alcoholic since 23 years 
Chronic smoker for 10 years and stopped smoking 
Family history: 
No family history 
General examination: 
Coherent and Conscious 
Cooperative 
No malnutrition 
No pallor 
No icterus 
No cyanosis 
No clubbing of fingers 
No lymphadenopathy
Pedal odema for 1 month 
Systemic examination: 
Temperature: 98.5 F 
Pulse rate : 86
Respiration: 16/ min
BP: 100/ 70
Spo2: 98% 
Investigations: 
I  
 
       provisional diagnosis: Chronic liver disease, splenomegaly 

Comments

Post a Comment

Popular posts from this blog

A 23 year female with fever and productive cough

Image
Hi, I am P.Madhuri of 3rd semester .This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio. The patient’s consent was taken verbally prior to history taking and examination of her condition. CHIEF COMPLAINT: A 23year female patient who is a worker came to the casualty on 15thof July with complaints of high fever with chills and productive cough.                                           HISTORY OF PRESENT ILLNESS: The patient had a fever spike so came for consultation.she again had a fever spike that is resolved spontaneous then she had no fever spikes. She underwent hemogram on 10 august no fever spike from 10 august. HISTORY OF PAST ILLNESS: No history of similar complaints in the past. Not a K/C/O HTN/T2DM/ASTHMA/CAD/CVA/EPILEPSY/TYPHOID head ache occasionally that is relieved by medications Tubectomy 3 months ago Hypothyroidism during pregnancy. 
Read more

A 51 year old male patient came to old with chief complaints of shortness of breath since 2 months

Image
 Hi I am Madhuri palsa ,6th sem medical student .this is an online e blog to discuss our patients deidentified health data shared after taking his /her /guardian signed informed consent  51M farmer by occupation , resident of nalgonda ,came to opd with c/o shortness of breath since 2 months HOPI  Patient was apparently asymptomatic 2 months ago then he developed SOB of insidious onset, gradually progressive increasing in intensity since 2 months (Glade II- III) No h/o constipation , nausea , vomiting ,burning micturation  PAST HISTORY : N/k/c/o DM , HTN , CAD,TB, epilepsy , thyroid disorders  FAMILY HISTORY :  not significant  PERSONAL HISTORY :  Decreased apetite  Mixed diet  Decreased bowel movements  Normal micturation  No known allergies  Alcoholic since 3 yrs  GENERAL EXAMINATION : I have examined the patient after taking prior consent and informing the patient in the presence of a attendant. The examination was done in both supine and sitting position in a well lit room.  - patie
Read more

A 50 year female patient with viral pyrexia

Image
a 50 years old female patient with viral pyrexia  August 23, 2022 Iam P.Madhuri,3rd semester medical student.this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.    Chief complaint: A 50 years old female patient came with fever and pedal edema. History of present illness: the patient was apparently asymptomatic 1 week back. She had fever since 1 week and said that there was increased temperature at night and diurnal variation in temperature. She had pedal edema since 1 week.she was suffering with constipation since 2 years, passing stools once for 3 days. she had vomiting and loose stools with mucous 6 times ,with no blood 1 week back. She is also complaining of burning micturition since the time of fever.  History of past illness: no history of hypertension,diabetes mellitus,epilepsy,CAD,tuberculosis, thyroid,asthma. Under went hysterectomy. Personal history:  Appetite: normal Bowels:
Read more