This is a HIPAA de-identified open-online-patient-record with initial information in duty-doctors notes as well as patient's voice, posted here winter-spring 2015 after collecting informed patient consent (form downloadable here) by LNMCH research assistant and patient-information-communication-executive for a discussion initiated by patient's primary care physician in-charge:
History:
By Dr Arun Chaudhury:
Age - 37/ male
Occptn - LDC in court .. Self job
Religion - Hindu
Address - jk town campus ..bhopal mp
Present complaints - non digestive system ..abdomen pain ..blackish skin or dull face swelling at half tibia fibular region and both of foots , liver disorder like hepatitis condition bcozzz of liver damage and low function of liver bcozzz of using I
Of liquor ..
Past complain - pt was good at job .pt was got married in 2003 then he got married .pt was lived for 5 years after marriage at his wife's home this matter takes depression in patient mind ..so patient is going to be alcoholic n then abdomen pain and gastric pain in stomach and intestine ..swelling in lower extremities and foots ..
Eyes - normal
Skin - browny
Appetite - not well
Patient is jealous and sensitive
Stool - well but some pain .
Urine - not OK ..
Smoking - some smoke .
Liquor - occasionally ..
Pan masala - no or occasionally ..
Pure vegetarian ..
Gait - default of swelling ..
Slight cough ..
BP - 110/60 mg/ dl
Pulse - 67/min
RR- 21/ min
GC - stable
History by Dr Varsha:
History:
By Dr Arun Chaudhury:
Age - 37/ male
Occptn - LDC in court .. Self job
Religion - Hindu
Address - jk town campus ..bhopal mp
Present complaints - non digestive system ..abdomen pain ..blackish skin or dull face swelling at half tibia fibular region and both of foots , liver disorder like hepatitis condition bcozzz of liver damage and low function of liver bcozzz of using I
Of liquor ..
Past complain - pt was good at job .pt was got married in 2003 then he got married .pt was lived for 5 years after marriage at his wife's home this matter takes depression in patient mind ..so patient is going to be alcoholic n then abdomen pain and gastric pain in stomach and intestine ..swelling in lower extremities and foots ..
Eyes - normal
Skin - browny
Appetite - not well
Patient is jealous and sensitive
Stool - well but some pain .
Urine - not OK ..
Smoking - some smoke .
Liquor - occasionally ..
Pan masala - no or occasionally ..
Pure vegetarian ..
Gait - default of swelling ..
Slight cough ..
BP - 110/60 mg/ dl
Pulse - 67/min
RR- 21/ min
GC - stable
History by Dr Varsha:
new notes & investigation images
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