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 

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