A 20 YRS OLD MALE CAME TO OPD WITH CHIEF COMPLAINTS OF YELLOWISH DISCOLORATION OF EYES

 E LOG GENERAL MEDICINE.

Hi, I am Anvitha,5th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.

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•  * This is an ongoing case. I am in the process of updating and editing this ELOG as and when required

•                                CASE SHEET.                                            

  Chief complaints and duration.

  A 20 yrs old male came to opd with chief complaints of Yellowsish discoloration of eyes.

  History of present illness.

  patient was apparently asymptimatic since one year back then developed Yellowsish discoloration of eyes 

  POSITIVE HISTORY

  Loss of appetite

  Irregular bowel and bladder movements

  Adipsia

  NEGATIVE HISTORY:

  N/K/C/O: TB , Asthma, epilepsy, thyroid

  Personal history.

  Mixed diet

  Irregular bowel and bladder movements

  Adipsia

  No addictions

  Sleep adequate

  
  

  Family history.

  No significant family history.

  PHYSICAL EXAMINATION.

  A. General Examination 

  The patient was conscious coherent and well oriented to time place and person and was examined in a well lit room.

  Pallor is absent.

  Icterus is absent

  No cyanosis

  No clubbing of fingers

  No lymphadenopathy

  No malnutrition 

  No clubbing of fingers

  No oedema of feet and hands.

  
  

  VITALS:

  Temperature :afebrile

  Pulse:86bpm

  Bp:100/70 mmhg

  
  

  SYSTEMIC EXAMINATION

  B. Cardiovascular system 

  No thrills 

  No cardiac murmurs

  Cardiac sounds: S1 and S2

  C. Respiratory system

  dyspnea absent 

  No wheezing

  Vesicular breath sounds 

  Position of trachea - central

  D. Abdomen

  Abdomen is scaphoid

  No tenderness

  No Palpable mass 

  Bowel sounds are present 

  No bruits

  No free fluids

  E. Central nervous system

  The patient was conscious coherent and cooperative.

  No neck stiffness 

  No kernick sign

  Speech normal

  
  

  Tone                 Rt                  Lt

  UL                     N                   N

  LL                      N                   N

  
  

  Power               Rt                  Lt

  
  

  UL                    5/5                 5/5

  LL                     5/5                 4/5

  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  Provisional diagnosis:

  Patient was diagnosed with secondary jaundice.