GENERAL MEDICINE :

A 40 year's old male with abdominal distension, shortness of breath and yellow discoloration of eyes
1/6/2023

Hi iam Likitha 3rd semester student. This is an online elog book to discuss our patients health data after taking his consent, this also reflect my patient centered online learning portfolio. 
Case sheet:
A 40 yr old man, lorry driver by occupation, resident of survellu came to medicine OPD with
Chief complaints of:
•Abdominal distension since 4-5 days. 
•Abdominal bloating since 4-5 days. 
• Shortness of breath since 5days.
•yellow discoloration of eyes since 5 days. 
•Vomiting since 3 days. 
•B/L lower limbs swelling since 15-20 days. 
History of presenting illness:
Patient was apparently asymptomatic 15 days back , then he developed B/L lower limbs swelling since 15 days then followed by shortness of breath, abdominal distension, yellow discoloration of eyes since 5 days. 
History of past illness:
K/C/O:DM(since 5 yrs) 
NK/C/O:HTN/TB/ASTHMA/CAD/EPILEPSY
Personal History:
Married
Appetite:lost
Diet:mixed diet
Bowel movement:normal
Micturirion:normal
Sleep:normal
Addiction:
Alcohol:regular (since 10 yrs) 
Smoking(beedi) :regular (1pac daily , since 20 yrs) 
Family History:
Mother:HTN
Drug History:
On metformin since, 5 yrs. 
Physical Examination:
General Examination:
Patient was conscious ,coherent and cooperative. 
Icterus: present
Pedal oedema : present
No pallor
No cyanosis
No clubbing of fingers
No lymphadenopathy
Vitals:
Temperature: afebrile
Pulse rate:116
RR:18 per minute
BP:130/70
SPo2:93%
Systemic Examination:
Cardiovascular system:
•no thrills
•cardiac sounds S1&S2 heard. 
•no cardiac murmurs. 
Respiratory system:
Dyspnea:present
No wheezing
Central trachea
Vesicular breath sounds
Abdomen:
Distended abdomen
No tenderness
No palpable mass
No palpable liver and spleen
Bowel sounds heard
CNS:
Patient was coherent 
Normal speech

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