GM CASE 4

8th  AUGUST  2023      

Case scenario 

Hi, This is M sindhuja, 3rd bds. This is an online eblog book discuss our patients health data after taking her consent. This also reflects my patient centered online learning portfolio. 

Case sheet:

CHIEF COMPLAINT AND DURATION:  
       A 57yrs old male c/o yellowish discoloration of eyes since 3 days. 

HISTORY OF PRESENT ILLNESS(HOPI):
                           Patient was apparently asymptomatic 35yrs back and then started alcohol consumption in the form of toddy and attack. Initially he used to 180ml occasionly at night, he gradually stopped arreck because of unavailability but continued toddy. After 5yrs, he shifted from toddy to whiskey initially 180ml (2-3times) per week. 
Since 5 yrs, pateint drinking 12-16unit per day. he got admitted to hospital for jaundice, ascities then he was abstinent for 2yrs. Since 1yr again patient started to drink alcohol. 
Patient then stopped drinking 2 days back,because he was on herbal medication. from today morning he is unable to speak and not recognize patients relatives. 


HISTORY OF PAST ILLNESS:

Patient c/o h/o abdominal distension since 3 yrs ago (1 episode) 
Patient c/o h/o withdrawl seizures since 4 yrs. 
Not a k/c/o HTN, CAD, CVA, Epilepsy, TB, Asthma. 
No past surgeries done. 

PERSONAL HISTORY:
Patient occupation :agricultural labour, 4yrs ago was a lorry driver. 
Diet:mixed
Appetite :normal
Bowl and bladder movement: regular
Micturation :normal
No known allergies. 
Habits:
            Alcohol-35yrs ago (180ml whiskey) 16-24units per day. 
Tobacco chewing:35 yrs daily(3-4packs/2-3days).

FAMILY HISTORY:
                           No significant family history. 

GENERAL EXAMINTION: 
                                            Patient was conscious,cooperative,coherent.
  VITALS: 
    Temperature :afebrile
    Pulse rate:86/min
    Spo2: 98%                                               GRBS:135mg% 
     Respiratory rate:16
     Blood pressure :120/90

SYSTEMIC EXAMINTION:
ABDOMINAL:
INSPECTION:

Shape of abdomen -distended. 
Full flanks. 
Umbilical hernia is normal. 
No distended veins, visible pulsation, visible peristalsis are present.

PALPATION:
No local rise in temperature 
No tenderness 
Lower border of liver and spleen are not palpable.
No free fluid present 
No palpable masses 

PERCUSSION: 
Liver span upper border of liver dullness in 5th intercoastal space in mechanical line. 
Lower border cannot be appreciated. 

ASCULTATION:
No hepatic bruit. 
Normal bowl sound heard. 

PROVISIONAL DIAGNOSIS :
?Hepatic encaphalopathy Associated with withdrawl alcohol. 

FINAL DIAGNOSIS:
k/c/o chronic liver disease. 

INVESTIGATION:

                                         
   


Popular posts from this blog

GM CASE 3

Image
60 YRS WITH SOB 10th March 2023 Case scenario......     Hi, This is M sindhuja, 3rd bds. This is an online eblog book discuss our patients health data after taking her consent. This also reflects my patient centered online learning portfolio.  Case Sheet: CHIEF COMPLAINTS AND DIRATION:  Patient c/o cough duration:1 week back.  Shortness of breath:1 week back Fever with chills and rigor on and off since 1 week.  HISTORY OF PRESENT ILLNESS(HOPI):  Patient was apparently asymptomatic until 1 week. Then developed cough with sputum ( mucous, whitish in color, non foul-smelling, non blood stained, aggrevated during night, seasonal variation. Releived with medication.  Breathlessness/dysponea with grade 2 mmrs, aggrevated Associated with cough. More in supine position, no releiving factors.  Fever with chills and rigor low grade on and off 1 week back.  HISTORY OF PAST HISTORY: No h/o chest pain, chest tightness, palpitation. No h/o TB, loss of weight, loss of appetite. k/c/o DM with medicati
Read more

GM CASE 2

Image
6th March 2023 Case scenario.......  Hi, This is M Sindhuja, 3rd year Bds. This is an online eblog book. Discuss our patient health data after taking his consent. This also reflects my patient centered online learning portfolio.  COMPLINTS AND DURATION   77yrs old male farmer by occupation Resident of narayampuram c/o abdomen pain since 5 days.  History of present illness (HOPI)     Patient was apparently asymptomatic until 5 days back.later,c/o abdomen pain with twisted type of pain onset in insidious accompanied with nausea. gradually progressive after taking food.  History of past illness :   Patient c/o  Similar complaint 15 yrs back.  Patient h/o emphysema 15 yrs ago, h/o analgesia abuse for knee pains since 3 yrs.  h/o cholecystitis Moderate ascities.  No k/c/o DM, Hypertension, CAD, Asthma,TB,Blood transfusion.  PERSONAL HISTORY: Patient has normal appetite and mixed diet, bowl( constipation), micturation(decreased urine output), burning of micturation, no known allergies.  Pati
Read more