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.

  • This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING.
  •  * 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.



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