50Years old female

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

50YEARS OLD FEMALE PATIENT CAME TO GM OPD WITH 

CHIEF COMPLIANTS:

Abdominal pain since 5months 

Itchy lesions on abdomen since 1 year 

HOPI : 

 Patient was apparently asymptomatic 5 months ago then she developed abdominal pain insidious in onset non progressive in epigastric region and right hypochondrium,later progressive to diffuse abdominal pain. pain is more after eating food,not radiating.

N/H/O vomiting,loose stools ,hematemesis,fever ,cough ,SOB, palpitations.

 occasionally pedal edema present .

Itchy lesion on abdomen since 1 year (took treatment)

PAST HISTORY:

N/H/O similar complaints in the past  

N/K/C/O DM ,HTN ,TB ,ASTHMA , THYROID, EPILEPSY.

PERSONAL HISTORY:

Appetite: Normal 

Sleep - Adequate

Bowel and bladder - Regular 

Addiction - occasional toddy intake 

TREATMENT HISTORY:

Not significant

FAMILY HISTORY:

Not significant

GENERAL EXAMINATION:

Patient is concious, coherent, cooperative

Well built and Nourished.

Vitals : 

BP -140/90

PR-78

RR-18

TEMP -96.8

No pallor, icterus, clubbing, cynosis

Pedal edema - occasionally present (Non pitting type )

SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM:

Inspection: chest shape normal, 

No scars , no engorged veins 

Movement of chest both sides 

AUSCULTATION :

Bilateral air entry 

Normal vesicular breath sounds 

PALPATION:

Trachea central 

CVS :

S1,S2 - heard 

No murmur

Abdominal examination: 

Shape : scaphoid

Tenderness -no 

Free fluid -no 

Liver,spleen -not palpable 

CNS: 

Higher mental status intact 

REFLEXES are intact 

No focal neurological deficit 

Investigation:

Chest x ray - 

ECG :

  

Other : 

USG :

IMPRESSION-  GARADE 2 FATTY LIVER 

DIAGNOSIS:

? ALCOHOL GASTRITIS ? FATTY LIVER