Hi , I am Samhitha ,3rd semester student. This is an online elog book to discuss our patients health data after taking his consent. This also reflects my patient centered online learning portfolios

26 year old man, resident of ammaram came to causality with complaints of loose stools and generalised weakness

HISTORY OF PRESENT ILLNESSES 

Loose stools since 20 days (4 to 5 episodes per day), generalised weakness since 3 months with polyuria,polydypsia,polyphagia.

PAST HISTORY 

k/c/o Diabetics mellitus since 3 years
No hypertension 
K/c/o polio

TREATMENT HISTORY
For DM (stopped taking insulin 7 months ago)

PERSONAL HISTORY

Normal appetite 
Regular bowels
Mixed diet
Increased frequency of mituration
Loose bowels

FAMILY HISTORY

No hypertension
No diabetes
No heart disease
No cancers 
No asthma

GENERAL EXAMINATION
Pulse rate : 96per minute 
Respiratory rate : 18/min
B.p : 120/ 80 
Spo :96%
Icterus absent
Cyanosis absent 
Pallor absent 
No lymphadenopathy
No clubbing of fingers
No oedema 

SYSTEMIC EXAMINATION

 CVS

NO thrills
S1 ,S2 present
No cardiac murmurs


RESPIRATORY SYSTEM

NO dyspenoea
No wheezing
Central position of trachea
Vesicular breath sounds


ABDOMEN

Scaphoid shape of abdomen
No tenderness
No palpable mass
No hernial orifices
No bruits
No free fluids
No Bowel sounds 
No palpable liver and spleen


CNS

Patient is alert
Normal speech
No neck stiffness
No kemings sign

Normal gait

BIOCHEMICAL INVESTIGATIONS


Popular posts from this blog

Hi, I am p.samhitha 5th Sem Medical Student.This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent

Image
A 63Y/M with loss of consciousness 6 hours ago  Hi, I am p.samhitha 5th Sem Medical Student.This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.  Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered 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 a diagnosis and treatment plan. Patient came to casuality with the history of loss of consciousness at 3 pm today .  HISTOR...
Read more

Hi , I am Samhitha ,3rd semester student. This is an online elog book to discuss our patients health data after taking his consent. This also reflects my patient centered online learning portfolios

Image
A 55 year old woman, came to causality with complaints of sudden lose of consciousness with palpitations  HISTORY OF PRESENT ILLNESSES Sudden lose of consciousness (30 minutes) Palpitations are present PAST HISTORY Patient suffering with Type 2 DM  since 2yrs(on medication) Hypertension since 2 years  TREATMENT HISTORY For DM since 2 Yrs PERSONAL HISTORY Normal appetite  Regular bowels Normal mituration Mixed diet FAMILY HISTORY No hypertension No diabetes No heart disease No cancers  No asthma GENERAL EXAMINATION Pulse rate : 60 per minute  Respiratory rate : 20/min B.p : 160/90 Spo :99% PALLOR PRESENT  Icterus absent Cyanosis absent  No lymphadenopathy MENSTRUAL HISTORY  Menopause  SYSTEMIC EXAMINATION  CVS S1 ,S2 present No cardiac murmurs RESPIRATORY SYSTEM Bronchial artery embolisation  ABDOMEN Scaphoid shape of abdomen No palpable mass No hernial orifices No bruits No free fluids Bowel sounds heard No palpable liver and s...
Read more

Hi , I am Samhitha ,5th semester student. This is an online elog book to discuss our patients health data after taking his consent. This also reflects my patient centered online learning portfolios

Image
Hi, I am p.samhitha, 5th Sem Medical Student.This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.  Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered 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 a diagnosis and treatment plan. CHIEF COMPLAINTS  Pt came with  -c/o giddiness since 1 yr -c/o headache since 1 yr HISTORY OF PRESENTING ILLNESS: Pt was apparently asympt...
Read more