A 55-year old woman came to the OPD with cheif complaints of abdominal distension and tightness since 15 days


August 16,2022

Hi, I'm Nandini Mudari, 3rd Sem medical student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent. This also reflects patient centered care and online learning portfolio.

This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end.

CHIEF COMPLAINTS:
C/O Abdominal distension since 15 days and abdominal tightness since 15 days 

HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 10 years back.
Now since 15 days she had abdominal distension and tightness for which she was frequently visiting our hospital and she was told to admit on 04/08/22
No history of pain and vomiting.

HISTORY OF PAST ILLNESS:
K/C/O Asthma since 5 years on inhalation of formetrol fumarate and budesonide
K/C/O Hypothyroidism since 10 years on medication thyronorm 50 mcg Stopped in middle and started 2 years back
K/C/O Diabetes since 10 years On medication of metformin 500 mg
K/C/O Hypertension since 10 years On medication of Telma 40 mg
Not a K/C/O of CVA/CAD/Epilepsy/TB

PERSONAL HISTORY:
She is married and house wife
Appetite: Normal
Non-vegetarian
Bowel: Regular
Micturition: Normal
No known allergies

ADDICTIONS:
Not an alcoholic
Chewable tobacco since 10 years
No H/O drug intake
No H/O betel nut intake
No H/O betel leaf intake

FAMILY HISTORY:
No H/O Diabetes, hypertension, heart diseases, stroke, cancer, tuberculosis, asthma

PHYSICAL EXAMINATION:
General examination:
Pallor-Present
Icterus-Present
Cyanosis-Absent
Clubbing of fingers and toes-Absent
Lymphadenopathy-Absent
Edema of feet-Absent
Weight-57 kg

Vitals:
BP: 120/80 mm Hg
Pulse Rate: 102 bpm
Temperature:99.5°F
SpO2: 98%

Systemic Examination:
• CVS
  No thrills
  S1 and S2 heard
  No cardiac murmurs
• Respiratory system
  No dyspnea 
  No wheezing
  Trachea-central
  Vesicular breath sounds
  Rales- 1 rub
• Abdominal Examination
  Shape of abdomen: Distended[Abdominal girth 88.5 cm]
  No scars
  No sinuses
  No visible mass
  Slit like umbilicus
• CNS
  HMF intact
  Cranial nerves intact
  No focal neurological defects

 


ECG:
Investigations:
Treatmeant:
DIAGNOSIS:
Chroniv liver disease secondary to NAFLD


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