General Medicine E-log

A 57 year old female presented to the OPD with complaints of pain abdomen and yellowish discolouration since 2 months.

Chief Complaints:

A 57 year old female home maker, resident of West Bengal came to the OPD with complaints of

Pain in the abdomen since 3 and a half months

Decreased appetite and weight loss since 2 months

Itching all over the body since 2 months

Yellowish discolouration of eyes, skin and urine since 1 month

History of presenting illness:

Patient was apparently asymptomatic 3 and a half months ago when she she had mild stomach ache which was intermittent, insidious in onset, gradually progressive. It is of pricking type and non radiating. Pain was aggravated by putting pressure on the abdomen and eating food. She also had decreased appetite since 2 months. She visited a hospital in West Bengal for these complaints where she was diagnosed with type 2 diabetes mellitus for which she was started on medication. She was referred to KIMS.

Past history:

History of

Hysterectomy done for tumour of uterus in 1996.

Bronchial asthma since 30 years for which she is on medication ( Tab. Deriphylline 450 mg 1/2 tablet PO/ BD).

Diabetes mellitus since 2 months for which she is on medication (Tab. Dapagliflozin 10 mg in the morning and Tab. Sitagliptin 50 mg and Tab. Metformin 500 mg at night).

N/K/C/O HTN, epilepsy, thyroid disorders, CAD or CVA

Personal history:

Diet: mixed

Appetite: decreased

Sleep: adequate

Bowel and bladder movements: normal

No known allergies or addictions

Family history :

Not significant

General Examination:

Patient is conscious, coherent and cooperative.

Pallor is present

Icterus is present

Cyanosis, clubbing, generalised lymphadenopathy or pedal edema

Vitals:

Temperature: afebrile

PR: 82 bpm

RR: 16cpm

BP: 110/70 mmHg

Systemic Examination:

CNS:

Speech: normal
No signs of meningeal irritation
Motor & sensory system: normal
Cranial nerves: intact

CVS:

S1, S2 were heard

No Murmurs
No thrills

Respiratory system:
Position of Trachea: central
BAE: present
NVBS heard
No added sounds

Per Abdomen:
Soft, non tender, no organomegaly
Hernial orifices are normal
No palpable masses
Bowel sounds heard

Provisional diagnosis: Obstructive jaundice with type 2 DM

Yellowish discolouration of bulbar conjunctiva