A 20 YRS OLD MALE CAME TO OPD WITH CHIEF COMPLAINTS OF YELLOWISH DISCOLORATION OF EYES.

Hi I am, Aswin (roll no:18), 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.

History of presenting illness:
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

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

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
PROVISIONAL DIAGNOSIS:
Patient was diagnosed with 2' jaundice


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