Case no: 1

Patient name: Jannat bibi Age: 64yr Gender: female Weight: 67 kg Address: baraf wala cowk, jalo mor lahore Heights: 56 Race: Asian Allergies: no

Chief compliant:
Abdominal fullness and feel abdominal pain during cough.

History of present illness:

Patient is week with no proper diet and poor fluid intake, an diagnosed as a patient of malnutritient.

Past medical history:

Patient is diagnosed as a patient of CHRONIC LIVER DISEASE.

Social history:
She is house wife and economic state is low. Her mother was a patient of HEPATITIS C.

Family history:
Patients have 5 healthy children. Except one was cured form dengue.

Review of system:
CVS: pulse rate 80/ MIN.b.p. 110/70mmhg, Pale colour CNS: fully conscious GIT: normal RESPIRATORY: normal Musculo skeletal system: muscle activity weak ENT: normal Eye: normal

Physical examination:

VITAL SIGNS: T 96, Pulse 80/ Min, BP 110/70, GENERAL: Weak appearing female in mild distress PALOR: YES JAUNDICE: YES

Laboratory and diagnostic test:

Ultrasonography: ascities fluid is present in pelvic region
LIVER PROFILE: TEST AST / SGOT GGT /GGPT Bilirubin RBC (female) Hemoglobin(femal e) Differential WBC count neutrophil Sodium Potassium Creatinine Urea nitrogen CPK (female) CK.MB LDH HCT LYMPH PCT RLT HGB PATIENT VALUES 54IU/L 69IU/L 2.9mg/dl 3.20million/microl iter 6.9(10)3/mm 2.1% 137meq/I 3.7meq/I 1.0mg/dl 28mg/dl 210u/I 18% 375u/I 22.7 34 0.08 84 7.7

Blood profile

Electrolyte Renal profile Cardiac profile others

Diagnose:
PRIMARY DIAGNOSIS:
CLD due to hepatitis

SECONDRY DIAGNOSIS:
Hepatitis B and c