general medicine 4
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Roll no : 41
2020 Batch.
Chief complaints : 44 year old male came to OPD with chief complaints of loss of appetite since 1 month , cough and expectoration since 10 days and sob since 3 months.
HOPI : patient was apparently asymptomatic ten years back . Then he developed loss of appetite , yellowish discoloration of sclera. Then he went to local hospital and was told he had jaundice.and relieved on herbal medication then he was fine till one month back .then he developed loss of appetite since then he had decreased intake of food then he developed with expectoration .sputum is scanty and whitish colour cough increase at night then he developed shortness of breath since 4 days no history of cold fever body pains headache nausea vomiting chest pain and palpitations.
Past history :
No history of DM,Htn,asthma,tb and any allergies.
Family history : no history of similar complaints in the family.
General examination :
Conscious, coherent, co-operative
Moderately built,nourished
PALLOR: ABSENT
ICTERUS:ABSENT
CYANOSIS: ABSENT
CLUBBING OF FINGERS/TOES: ABSENT
LYMPHADENOPATHY: ABSENT
PEDAL EDEMA: ABSENT.
VITALS:
TEMPERATURE: 98.7
PULSE RATE:120 / min
RESPIRATORY RATE : :28
BP: 140/70
SPO2:92
GRBS:125
Investigations :
Diagnosis: chronic liver disease
