GENERAL MEDICINE ELOG

23 December 2021

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

 Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

 This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment .

Patient and his/her attenders have been informed and their consent has been taken.

SNEHA JAJU

Roll no 148

A 44 YEAR OLD FEMALE WHO IS K/C/O HYPOTHYROIDISM, HTN AND DM CAME FOR REGULAR CHECK UP.

A 44 Year old female who is known case of Hypothyroidism, Hypertension and Diabetes mellitus came for regular check up.

HOPI

Patient was apparently asymptomatic 17 years back, then she was incidentally diagnosed with stones in gall bladder for which she underwent surgery. She was also diagnosed with Hypothyroidism in 2004.

In 2008, She was diagnosed with Hypertension.

In 2013, she was diagnosed with Diabetes mellitus.

In 2019, while undergoing routine ultrasonography examination she was diagnosed with Non alcoholic fatty liver disease with portal hypertension.

One year back she had palpitations twice.

Recently she is diagnosed to have bilateral cysts in ovary.

PAST HISTORY

She is known case of Hypothyroidism, Hypertension and Diabetes mellitus

No history of Asthma, Tuberculosis, CAD, CKD.

She underwent Caeserean section in 2010.

PERSONAL HISTORY

Diet - Mixed

Appetite - Normal

Sleep - Disturbed

B/B - Regular

No addictions and no allergies.

FAMILY HISTORY

Father and Mother are k/c/o of Hypertension and Diabetes mellitus.

Physical Examination:

Patient is conscious , coherent and cooperative and well oriented to time, place and person.

General:

Pallor - Absent

Icterus -  Absent

Cyanosis - Absent

Clubbing - Absent

Lymphadenopathy - Absent

Pedal Odema - Absent

Temp - Afebrile 

BP- 130/90 mmHg

Rr - 18cpm

PR- 94bpm

SpO2-98%

Grbs- 155mg/dl

Systemic:

CVS:

Cardiac sounds - S1+ S2 +, No murmurs

Respiratory:

BAE+

Position of trachea central

Abdomen:

Soft, Non tender

CNS:

No Focal Neurological Deficit.

INVESTIGATIONS

PROVISIONAL DIAGNOSIS

NON ALCOHOLIC FATTY LIVER DISEASE WITH PORTAL HYPERTENSION

TREATMENT

1. TAB GLIBETULIO MET 12.5/500mg

2. TAB PROPRANOLOL 20mg OD

3. TAB OLMEZEST 40/5 mg

4. TAB THYRONORM 112mg OD

5. TAB AZTOR 5mg OD

6. TAB HEPTAGON 1 Tab OD