A 35 year old male came to general medicine OPD with chief complaints of lower limb swelling & abdominal swelling

26/12/2022 

 I am K.Sai Rithindar Reddy of 3rd semester .This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio.

The patient’s consent was taken verbally prior to history taking and examination of his/her condition.

CASE DISCUSSION: 
A 35 yr old male who is driver by occupation resident of atthampeta came to opd

CHIEF COMPLAINTS: 
Lower limb swelling
Abdominal swelling associated with pain 

HISTORY OF PRESENT ILLNESS: 
patient was apparently asymptomatic 25 days back he developed swelling in the lower limbs bilaterally below knee joint and distension of abdomen . He went to a hospital there he was diagnosed with jaundice & liver infection. Later he came to our hospital 13 days back . 

PAST HISTORY : 
No similar complaints in the past 
He is a known case of Diabetes Mellitus
No known case of HTN, Asthma,  TB,Epipepsy  
He had a surgery on the neck 13 years back 
one year back he met with an accident & has scar on his leg 

FAMILY HISTORY : 
Not significant

PERSONAL HISTORY: 
Diet : Vegetarian 
Appetite : Decreased 
Bowel & Bladder habits : Irregular 
Sleep : Inadequate 
Addictions : Alcoholic & tobacco 

GENERAL EXAMINATION: 
Conscious, coherent, co-operative
Moderately built,nourished
PALLOR: ABSENT
ICTERUS:PRESENT
CYANOSIS: ABSENT
CLUBBING OF FINGERS/TOES: ABSENT
LYMPHADENOPATHY: ABSENT
PEDAL EDEMA: PRESENT
VITALS:
TEMPERATURE: 
PULSE RATE:
RESPIRATORY RATE:
BP:
SPO2:
GRBS:


SYSTEMIC EXAMINATION:
CVS:
S1,S2 Sounds heard,
No audible murmurs,
Thrills:No.

RESPIRATORY SYSTEM:
Dyspnea is present,
Position of trachea:central,
Normal vesicular breath sounds are heard,
No adventitious sounds  

INVESTIGATIONS: 
USG : 
ECG : 
HEMOGRAM : 
SERUM ELECTROLYTES & LFT : 

PROVISIONAL DIAGNOSIS: 
Chronic Pancreatitis 
Hepatic Encaphalopathy 











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