53 M WITH DECOMPENSATED ALCOHOLICLIVER DISEASE WITH PORTAL HYPERTENSION WITHTHROMBOCYTOPENIA
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Hi, I am J. Harsha Vardhan Foreign Medical Graduate . This is an E-Log, that depicts the patient centered approach for learning medicine .This E-Log has been created after taking consent from the patient and their relatives. The links that were used by me for understanding the available data on the particular disease have been mentioned below in each post . Hope you learn valuable information after giving it a good read!
CHIEF COMPLAINT
This is a case of a 53-year-old male, a Hotel owner and chief by occupation,
The patient presented to the hospital with chief complaints of
Swelling of both Legs since 20 days
Swelling of face since 7 days
Decrease intake of food since 20 days
HISTORY OF PRESENTING ILLNESS
The patient was apparently asymptomatic 20 days ago.
Then he developed Bilateral Pedal odema which is pitting type extending up to the knee, insidious in gradually progressive , since one week
Patient has decreased urine output since 10 days not associated with burning micturation
yellowish discolouration of urine
constipation since 15 days
No c/o - Chest pain, Palpitations , Shortness of breath ,Orthopnea, PND
No c/o - Fever , Vomitings , loose stools.
Not K/N/C- Hypertension, Epilepsy, Thyroid disorders.
K/C/O - Chronic Alcoholic since 20 yrs , every day consumption around 360 ml
Last consumption 1 week back.
PAST HISTORY
Patient was diagnosed with Poliomyelitis of upper limb and lower limb of left side in his early childhood age .
No past surgical history
FAMILY HISTORY
Patient was born to Congenious parents and was bought up in joint family house along with his other siblings. his father owns a farm lands which was divided among his father’s brother.
Patient was in good terms with his parents up to certain period of time.
Later than he has separated from then and use to live along with his wife parents in their house.after some years he moved out from his native place to another place along with his wife.
PERSONAL HISTORY
Appetite - Decreased for the past 7 days.
No Burning Micturation is present for the past 7 days
Constipation for 3-4 days with every episode
Sleep - adequate
Diet - Non-Veg & Mixed (Veg) sometimes
Chronic Alcoholic since 20 years
No allergies
Marital status-married twice
Patient had married twice. With his first wife he has 2 sons 1 daughter .
due to miss understandings between both husband and wife they decided to separate and got separated and he got married to another women . but his parents were not happy with their separation and didn’t allow his 2nd wife to enter their home.
After all familial fight with his parents and his 1st wife, he decided to leave his home and moved into his 2nd wife home and he has 2 daughters with is 2nd wife to.
Due to this familial separation and fight among them he lost his father farm lands.
Which made him to suffer lot of financial trouble.
OCCUPATIONAL HISTORY
Previously was a farmer in his farm land which was given to him before his 2nd marriage later he moved from his 2nd wife place to another city and started his own Hotel .
He's an alcoholic addict since 20yrs who use drink weekly but gradually it has become daily habit, he's everyday consumption was about 360ml since few months
Wakes up 6 am gets fresh up .
7am and goes to hotel and starts cooking
8am along with drinking alcohol and continues his work again he starts drinking 11:30am.
2pm - he takes lunch and sleeps till 5pm up get fresh up & start drinking 7pm .
Eats dinner at 8 and sleeps around 9 to 10.
GENERAL EXAMINATION
Patient was conscious ,non-coherent , cooperative ,well built and nourished not so well oriented to time place & person at the time of presentation.
Pallor- present
Icterus-present
Cyanosis-absent
Clubbing-present
Lymphadenopathy-absent
Edema -present b/l pitting type .
VITALS
Temperature-97.6'f
Pulse rate -90bpm.
Bp-150/80mm hg
RR-17cpm
Spo2-99% .
grbs-110mg/
Abdomen examination
INSPECTION:-
Shape of abdomen -distended
Umbilicus-inverted.
No scars ,sinuses,straie
No visible pulsations & visible peristalsis.
Moments of all 4quadrants moving equally with respiration
Abdominal Distension
Ecchymosis on Left shoulder
Icterus present
Bilateral Pitting Oedema
Percussion:-
Shifting dullness-+
No signs of fluid thrill.
CVS:-
S1,S2heard ,no murmurs.
CNS :-
Higher motor functions - intact
Cranial nerves - intact
Motor system:
Power : Rt-UL LL. Lt -UL LL
5/5 5/5. 5/5 5/5
Hand grip. 100%. 0%
Reflexes:
UL. LL
Biceps. 2+. +2
Triceps. 2+. +2
Supinator. 0 0
Knee 0 2+
ankle jerk cannot be seen due to pedal edema? Sensory system: intact
Hi, I am J. Harsha Vardhan Foreign Medical Graduate . This is an E-Log, that depicts the patient centered approach for learning medicine .This E-Log has been created after taking consent from the patient and their relatives. The links that were used by me for understanding the available data on the particular disease have been mentioned below in each post . Hope you learn valuable information after giving it a good read! CHIEF COMPLAINTS Patient came with chief complaint of cough since 7 Days, Fever since 7 days, with difficulty in breathing since 7 days HOPI Fever since 15-days high grade-not associated with chills and rigor, evening rise + Associated with sweating Cough since 7- days associated with less amount of sputum, mucoid. blood tinged aggravated on changing position from lying down to sitting position, no reliving factors SOB grade - I MMRC -: 7 days more associated with cough, relieved on rest not associated with wheeze K/C/O: Dm+ since 2years H/o RTA 1 1/2 year back Frac
Hi, I am J. Harsha Vardhan Foreign Medical Graduate . This is an E-Log, that depicts the patient centered approach for learning medicine .This E-Log has been created after taking consent from the patient and their relatives. The links that were used by me for understanding the available data on the particular disease have been mentioned below in each post . Hope you learn valuable information after giving it a good read! CHIEF COMPLAINT This is a case of a 80-year-old female, who was a farmer . The patient presented to the hospital with chief complaints of C/o C/o HISTORY OF PRESENTING ILLNESS Detail history Pt was 3rd born child among 6 kids to the parents She had 2 brothers expired 10 years back and 1 sister expired 2 years Married around age of 20 Husband was ( shepherd) Expired 20 years ago She has total 6 kids 1 son expired- chronic alcoholic She was a farmer (20 years back)before stopped after her sons marriage taking care of theirs kids and cooking Smokes sut
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