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








A 54 year old woman, resident of nalgonda came to causality with complaints of decresed apetite , vomitings , fever and SOB.

HISTORY OF PRESENT ILLNESSES

Decresed apetite and vomitings since 6 to 7 days and fever since 7 days which is intermittent and relived on medications and SOB since 8 days.


PAST HISTORY

Patient suffering with Type 2 DM  since 30 yrs(on medication)
Hypertension since 20 years (on medication)

TREATMENT HISTORY
For DM since 20 Yrs
FOR HTN since 20 yrs

PERSONAL HISTORY

Decresed apitite
Regular bowels
Normal mituration
Chews betal leaf

FAMILY HISTORY

No hypertension
No diabetes
No heart disease
No cancers 
No asthma

GENERAL EXAMINATION
Pulse rate : 87 per minute 
Respiratory rate : 20/min
B.p : 130 / 80 
Spo :97%
PALLOR PRESENT 
Icterus absent
Cyanosis absent 
No lymphadenopathy

MENSTRUAL HISTORY 
Menopause 

SYSTEMIC EXAMINATION

 CVS
NO thrills
S1 ,S2 present
No cardiac murmurs

RESPIRATORY SYSTEM
NO dyspenoea
No wheezing
Central position of trachea

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

CNS
Patient is Alert
Normal speech
No neck stiffness


BIOCHEMICAL INVESTIGATIONS

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