General Medicine elog

 16 october 2023

A 25 year old female came with the chief complaints of back pain since 1 year.


Hi ,I am Ananya Nayak, 5th sem medical student. This is an online elog book to discuss our patient’s health data after taking her consent.This also reflects my patient centered online learning portfolio.


*HISTORY OF PRESENTING ILLNESSES:*
The patient was apparently asymptomatic 1 yr back then developed back pain which was severe, gradually progressive and non radiating.
The pain was aggravated on standing and relieved on rest and medication.
The pain was more during night and was associated with difficulty in breathing.

*PAST HISTORY:*

H/o trauma
N/K/C/O DM, HTN, Asthma or epilepsy

PERSONAL HISTORY-

Appetite-normal

sleep-adequate

Fdiet-mixed

Bowel and bladder movements-regular

No addictions 

*FAMILY HISTORY:* not significant

*GENERAL EXAMINATION:*
Patient was C/C/C and moderately nourished
No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No pedal oedema

*VITALS:*
Temp- Afebrile
BP- 110/60 mm
PR- 100bpm
RR- 20 cpm





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