53 P Samhitha
General medicine blog 4
7 March 2023
Name- Ajay
Age-20yrs
Sex -male
Occupation -student
Adress- koyalagudeum
Hi ,I am P.Samhitha 3rd year BDS student .
This is an online elog book to discuss our patient data after taking her concent this also reflects my patient centred online learning portfolio
Chief complaint- A known diagnosis of jaundice from 10 days
History of present illness- Patient went to a local doctor as he had multiple episodes of vomiting with yellowish colour along with food particles before 12 days and got diagnosed of jaundice 10days back.
Yellowish discoloration of the eye.
Patient has pain radiating from front to back in right hypochondrium region.
History of past illness
Taken poison 8 yrs back due to family issues and cured.
No surgeries.
Personal history-
Student
He is single
Non vegetarian
Alcoholic takes 180ml 2 to 3 times a day started from 4 years back due to peer pressure
No appetite
No proper sleep
Smoking from 3yrs
Bowel and micturition normal
No allergies
Family history- no significant family history
General examination -
No pallor
No cyanosis
No lymphadenopathy
No clubbing of fingers
Oedema on right hand palm
Provisional diagnosis- liver inflammation
Alcohol withdrawal