General medicine case discussion

April 24th Case scenario.......

Hi, I am M.Yamini , 5th sem medical 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.

CASE SHEET:The 60 year old male occupation by village volunteer came from thanamcharla to general medicine opd (Date of admission:19th April)

Chief complaints:
Abdominal Distension,since 7 days .

HISTORY OF PRESENT ILLNESS:
The patient was apparently asymptomatic,1 month ago but suddenly he develops pain in abdomen
Pain character: pricking type
Radiation:from umbilicus to left lumbar region
Aggregating factors: after eating
Relieving factors: while sleep
No associated factors
Abdominal distension: Since 7 days
Insidious in onset
Gradually progress to present size
Starting point: umbilicus
Diffuse type of Distension
Past history:
No h/o previous similar episode s
No h/ o previous surgeries
He developed jaundice 2 months back ,then he used herbal medicine for 5 day's,but jaundice didn't subside .then he went to khamam there was given medication for 15 days then jaundice subside.
No h/o tb , hypertension,DM, epilepsy,CVD, asthma
Family history:not significant
Personal history:
Appetite: Normal
Sleep: Adequate
Diet: previously mixed diet ,but vegetarian since 1 year 
Bowel & Bladder movement s: Regular
Addictions: Natusara since 30 years,per day he was taking 2 quoters
General examination:
Patient was conscious, coherent, cooperative
Moderately built,
Moderately nourished,
Pallor: Absent
Icterus: present
Cyanosis: absent
Edema: absent
Lymphadenopathy:absent
Vital s
Temperature: Normal 98.6 degrees
BP:130/70
Pulse:72
Respiratory rate: 13












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