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Hi , I am Samhitha ,3rd semester 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 portfolios


31yr old man (sob ,Abdominal distension)


Hello, I am p.samhitha , a 3rd semester medical student. This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio.

CASE SHEET:

CHIEF COMPLAINTS:
c/o 
- Shortness of breath of Grade IV since 15 days
- Abdominal distension since 20 days


HISTORY OF PRESENT ILLNESS:

Patient was discharged 15 days back with medication. He was on medication for the 5 days and stopped 2 days back.

He has decreased appetite and good intake since 2 days. 

Distension increased on eating and decreased on motion. 

He has taken alcohol and had eaten chocolates.

Dry cough since 5 days and took medication for the same.

Fever 2 days ago, relieved on medication.


PAST HISTORY:

h/o

No K/C/O DM, HTN, Epilepsy, TB, CAD. 


PERSONAL HISTORY:

Regular Bowel movements. 

Has normal micturition with no burning sensation.

Has no known allergies.

Decreased appetite.


FAMILY HISTORY:

Has no history of Diabetes Mellitus, No HTN, No Cardiac Strokes, No cancers.


DRUG HISTORY:


GENERAL EXAMINATION:

-No palor
-No cyanosis 
-No lymphadenopathy
-Icterus present
-No edema of feet
-No clubbing of fingers
-Temp - normal
-GRBS - 157




VITALS:

Temperature: febrile

Pulse: 116 beats per minute

Respiratory rate: — cycles per minute

Blood pressure: 110/60 mm of Hg

SPO²: 90

SYSTEMIC EXAMINATION:

Cardiovascular system:

No thrills
No murumurs
Cardiac sounds: S1, S2 present 

Respiratory system:

No dyspnea
No wheezing
Breath sounds heard: vesicular? yes

Abdomen:

Shape : Scaphoid
No tenderness
No palpable mass
Non palpable liver
Non palpable spleen
No bruits
Bowel sounds: heard

Central Nervous System:

Conscious and Alert 
Speech: Normal


Biochemical investigations:



ECG:



2D-ECHO REPORT:


ULTRASOUND REPORT:


GRAPHIC SHEET :


PROVISIONAL DIAGNOSIS:
———







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