Gm

  LOG GENERAL MEDICINE 


Hi, I am soumya , 6th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.

This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING.

 * This is an ongoing case. I am in the process of updating and editing this ELOG aChief complaints and duration.

Chief complaints : 

A 35 year old female , resident of chityal,  housewife by occupation , came to the OPD with chief complaint of headache, pain in the left side of neck, left hand and left leg since 3 days

 History of present illness : 
Patient was apparently asymptomatic 3 months back then she developed  headache, pain in the left side of neck , left hand and left leg which is sudden in onset, gradually progressive, dragging type of pain.
There is tingling sensation in the left upperlimb and left lowerlimb

No aggravating and relieving factors
No history of fever 

History of past illness :


Similar complaints in the past 
which is subsided by medication given by local rmp

Pain abdomen since 15 days which is relieved on taking medications 

No hypertension 
No diabetics

No TB

No CAD

No epilepsy

No Asthma

No thyroid

Family history : 

No significant family history 

Allergies : 

No allergies

Drug history 

Takes  dolo and paracetamol for pain 

Personal history : 

   
Appetite is normal

Mixed diet

Bowel and bladder habits are regular.

Sleep is adequate.

No addictions.


PHYSICAL EXAMINATION : 

A. General Examination

Oral consent is taken.

Examined in a well lit room.

Conscious , coherent and cooperative 

Moderatly built and nourished 

Pallor is absent

Icterus is absent.

No cyanosis

No clubbing of fingers

No lymphadenopathy

Pedal edema is absent.

Vitals : 

Temperature: afebrile

Pulse: 80 bpm

Respiration: 16/min

Blood pressure: 120/80mmhg  

Spo2: 96%

PHYSICAL EXAMINATION : 

A.Cardio vascular system :

Cardiac sounds : S1 and S2
No thrills  
No murmurs

B.Respiratory system : 

Position of trachea : centre 
Breath sounds : vesicular 
No added sounds.

C.Abdomen : 

Shape of abdomen : normal
No tenderness
No palpable mass
No organomegaly

Tone , power of limbs are normal

Cns examination- normal

Comments

Post a Comment

Popular posts from this blog

GM-1

Image
 July 7 , 2022 I'm Soumya donthi (rollno: 31) 3rd 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. CASE SHEET: Chief Complaint: A 70 year old patient who is farmer by occupation came to opd with a chief complaint of pedal edema since 10 days History of present illness: Patient was apparently asymptomatic 10 days then he developed pitting type of pedal edema upto ankle. History of past illness; Patient is a known case for Hypertension since 2 months No diabetes No TB No CAD No Epilepsy No Asthma Past history: No past history Personal history; Diet: mixed Appetite: normal Bladder/ Bowel movements: regular Sleep: adequate Addictions: alcoholic occasionally  Allergic history; No known allergies Drug history; No drug history Family history; No relevant family history  PHYSICAL EXAMINATION; General Examination: Patient is conscious, co
Read more
  Hi, I am soumya 3rd sem medical student.This is an online elog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio. CASE SHEET: Chief complaints:  22 year female came to causality with facial puffiness, decreased urine output,low back ache since 5 months HISTORY OF PRESENT ILLNESS: The patient was apparently asymptomatic 5 months back. She then developed facial puffiness followed by fever , chills, pedal edema , decreased urine output  PAST HISTORY No past history Personal history: Diet: Mixed Bowel : regular Micturition: normal Appetite: Decreased Habits: nil No history of allergy, asthma, tuberculosis, coronary artery disease. Family history: Insignificant GENERAL EXAMINATION: pallor present No icterus No cyanosis No clubbing No lymphadenopathy No malnutrition No dehydration No pedal edema VITALS: Temperature: 98.5 F Pulse: 86 beats per minute Respiratory rate: 20 cycles per minute Blood pressure: 110/90
Read more

Kidney disease

Image
Hi, I'm Soumya Donthi (roll:31) 3rd 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. CASE SHEET:- Chief complaint; A 29yr old female, resident of Mumbai, customer service executive by occupation came to OPD with chief complaints of Increased sweating 4days ago Shortness of breath 4days ago  Dizziness 4days ago Vomitings 2episodes/day before the day of admission  History of present illness; Patient was apparently asymptomatic 5yrs ago. Then she developed ulcers in mouth and painless rash on her face across her nose, hair loss and sensitivity to light on her face.Then she went to a private hospital where she was referred to another doctor where she was diagnosed with SLE. She was given medication for it. Then, 1 month ago, she developed Shortness of breath and went to hospital where she was diagnosed with kidney disease. She was pu
Read more