GM - 06

Hi , I am Shivani Veerabrahmam 3rd year dental student . This is online elog book to discuss my patient health data shared after taking his/her constent . This also reflects my patient centered online learning portfolio .

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

CASE SHEET :A 55 year old male patient came with a chief complaint of loss of appetite.


CHIEF COMPLAINTS :Loss of appetite, bloating.


HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic one month ago then he developed abdominal distension on consumption of alcohol which is insidious in onset and gradually progressive.
Fever since 10 days - high grade fever associated with chills ,rigors, intermittent fever which reduces on medication, diurnal variation - more during evening and night 
He is having burning micturation, abdominal pain, vomiting,loose stool.
No cough ,no cold ,no shortness of breath 

HISTORY OF PAST ILLNESS :
No Hypertension
No Diabetes Mellitus
No Asthma

PERSONAL HISTORY : 
Single/married : Married
Appetite : loss of appetite 
Veg/Non-Veg : Mixed
Bowels :Regular
Micturition :Regular
Known Allergies : Nil
Habits/Addictions : Alcohol
                                   Cigarette 

FAMILY HISTORY :Nil


GENERAL EXAMINATION : 
Pallor :No
Icterus :No
Cyanosis :No
Clubbing of fingers/toes : No
Lymphadenopathy :No
Oedema of feet :No
Malnutrition :No
Dehydration :No

VITALS :
Body temperature : 96.2F
BP : 100/80 mm/Hg
Pulse Rate : 88/min

PROVISIONAL DIAGNOSIS:
Chronic Liver Disease

Q/A
1. He stopped consuming alcohol will there be any withdrawal symptoms which may worsen the present condition?
2. Are there any other possible diagnosis with the given information?

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