General medicine case discussion

April 26 th 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 45 year old male occupation by driver came from narketpally to general medicine opd date of admission 21 st April.

Chief complaints:

Body shaking since 4 days  with slight rise of body temperature

History of presenting illness:

The patient was asymptomatic 4 days back then,he developed tremor s associated with fever.tremors are continuous with slight rise of body temperature.he had   3 episode s of vomiting, after drinking ors 

Vomiting

Non projectile

Non bilious

With food contents

Fever was first observed in the morning which is continuous and not associated with any factors.he didn't take any medication for fever

He was given 2 salines ,ors,by local rmp for weakness of the body .but tremor s didn't subside ,he referred to Kims

Past history:

Patient was asymptomatic 10 years back,then suddenly he developed cough with expectoration & yellowish discoloration of sclera ,then he was diagnosed with jaundice,for this he taken herbal medicine for 10 days Jaundice subside

5months back he was again diagnosed with jaundice for,which he came with similar complaints of tremor s & also he was diagnosed with slight hepatomegaly & treated 

He was given medication lorazepam diazepam

History of similar episode seen 5 months back

No history of DM, hypertension,tb, epilepsy, asthma,cvd

Family history:

His mother has no

Personal history:

Appetite: decreased

Diet: mixed

Sleep: inadequate

Bowel & bladder movement s: regular

Allergies:none

Addictions:

Alcohol consumption since 25 years

2 quarter s per day

Smoking:since 20 years ,1 packet per day

General examination

Patient was conscious, coherent, Non cooperative

Moderately nourished.