A 20 yrs old male came to opd with chief complaints of yellowish discoloration of eyes

Hi I am, A Satyanarayana (roll no:12), 5th sem medical student. This is an online e-log book to discuss our patient's health data shared after taking his/her consent . This also reflects my patient centered care and online learning portfolio.

Chief Complaints:

A 20 yrs old male came to opd with chief complaints of Yellowsish discoloration of eyes

HOPI:

patient was apparently asymptimatic since one year back then developed Yellowsish discoloration of eyes 

POSITIVE HISTORY

Loss of appetite

Irregular bowel and bladder movements

Adipsia

NEGATIVE HISTORY:

N/K/C/O: TB , Asthma, epilepsy, thyroid

PERSONAL HISTORY:

Mixed diet

Irregular bowel and bladder movements

Adipsia

No addictions

Sleep adequate

FAMILY HISTORY:

No relevent family history

SYSTEMIC EXAMINATION

CENTRAL NERVOUS SYSTEM

Conscious

No neck stiffness 

No kernick sign

Speech normal

Tone                 Rt                  Lt

UL                     N                   N

LL                      N                   N

Power               Rt                  Lt

UL                    5/5                 5/5

LL                     5/5                 4/5

RRSPIRATORY SYSTEM

Position of trachea: central 

No dyspnea

No wheeze

Breathe sounds :vesicular

CVS:

S1 and s2 are heard

No thrills 

No cardiac murmers

GENERAL EXAMINATION:

The patient was conscious, coherent , well oriented to time place person and was examined in a well ventilated room

No pallor

Icterus present

No lymphadenopathy

No clubbing of fingers

Well built 

Well nourished

No pedal edema

VITALS:

Temperature :afebrile

Pulse:86bpm

Bp:100/70 mmhg

PROVISIONAL DIAGNOSIS:

Patient was diagnosed with 2' jaundice