A 57 year old female was presented to OPD with yellowish discoloration of skin , conjunctiva , abdominal pain .

July 21, 2023

This is an online e log book to discuss our patient health data shared after taking his/her/guardians singned informed consent. Here we discuss our individual patients problems with an aim to solve the patient’s clinical problem with collective current best evident based input.

This E blog also reflects my patient cantered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of “patient clinical data analysis” to develop my competency in reading and comprehending clinical data including history, clinical findings,investigations and come up with diagnosis and treatment plan.

This is a case of 57 year old female , housewife staying in Mathavanga , West Bengal.

CHIEF COMPLAINTS:

- pain in abdomen( since 3 1/2 months {mild} , 2months {progressed} )

- tingling pain in the abdomen , sudden in onset. (increased on eating )

- can't stand / sit without support (since 1month)

- iching all over the body (since 1month)

- generalized weakness

- yellowish discoloration of sclera and skin and stools ( since 25 days ).

HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic 1 month back . She then developed abdominal pain followed by yellowish discoloration of skin, sclera and stools .

The patient visited a hospital in Mathavanga for the same and took medication following which the complaints didn't subside .

No aggrevating and relieving factors

PAST HISTORY:

The patient had tumour in her uterus 20 years ago for which she took medication.

She is diabetic and asthmatic ( uses inhaler ) .

She is anemic .

N/K/C/O hypertension, thyroid disorders, epilepsy.

PERSONAL HISTORY:

Vegetarian diet ( tried eating fish by was advised not to )

Normal appetite

Adequate sleep

Regular bowl movements