A 72 year old male

Hi , I am D Sai Deeptha I, 3rd semester student.  This is an online elog book to discuss our patients health data after taking her consent.  This also reflects my patient centered online learning portfolio.

A 72 year old daily wage worker, resident of Nalgonda was admitted into the hospital  with cheif complaints of jaundice since 10 days and fever since 5 days.

HISTORY OF PRESENT ILLNESSES: 

Patient came with the chief complaint of jaundice but later he was diagnosed with haemorrhoids once again. He had intermittent fever since few days. Has pain in left hypochondrium. Has pedal Edema since 15days..  

PAST ILLNESS:

Heamorrhoids: has since 3-5 years got treatment few years back. 

Chills, rigors, fever- since few days 

No cold , no cough

SOB-  present ( in supine position)

Vomitings :Nil 

Constipation - present 

Weight loss- present 

 PAST HISTORY:

HTN- was diagnosed 6 years back 

Diabetes- Present 

Family history-  2 sons suffering from polio , died 20 years ago 

Appetite- reduced since 1 month 

Diet- mixed

Sleep- reduced 

addiction- stopped drinking alcohol 50 years back 

GENERAL EXAMINATION :

Consious ,cooperative and coherent

Pallor- present

Icterus- present 

No cyanosis 

No clubbing of fingers

No lymphadenopathy 

Pedal edema - since 15 days 







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