General medicine Elog



 17 October 2023

Hi ,I am Ananya Nayak, 6th sem medical student. This is an online elog book to discuss our patient’s health data after taking his consent.This also reflects my patient centered online learning portfolio.

A 48 year old male patient came with the chief complaints of cold, cough and fever since 10 days.


HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic 10 days back, then he developed 

      Fever : sudden in onset

                   Intermittent in nature

                   High grade

Not associated with nausea, vomiting, chills, rigors or headache.

The cough was associated with sputum which was non blood stained.

 

PAST HISTORY:

N/K/C/O DM , TB, HTN,  epilepsy, Asthma and thyroid.

No history of similar complaints in the past.


PERSONAL HISTORY:

Appetite - decreased

Sleep - adequate 

Diet - mixed

Bowel and bladder movements - regular

No addictions


FAMILY HISTORY: Not significant 


GENERAL EXAMINATION:

Patient was C/C/C and slightly malnourished 

No pallor

No icterus

No cyanosis

No clubbing

No lymphadenopathy

No pedal oedema


VITALS:

BP-140/80 mm

RR- 20 cpm

PR- 76 bpm

Temp- afebrile.








Comments

Post a Comment

Popular posts from this blog

52M with PYREXIA ,SOB,BODY PAINS

Image
 30 October 2023 Hi ,I am Ananya Nayak, 6th sem medical student. This is an online elog book to discuss our patient’s health data after taking his consent.This also reflects my patient centered online learning portfolio. 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 based evidence based inputs. A 52 yr old male patient farmer by occupation came to the OPD with chief complaints of fever since 10 days . HISTORY OF PRESENT ILLNESS- Patient was apparently asymptomatic 10 days back.Then he developed fever which was high grade,sudden in onset, intermittent in nature aggrevated during night and on exertion. It is associated with body pains(aggrevated on exertion),chills and rigor.It is not associated with cough,cold,vomitings,headache. Patient has complaints of Shortness of breath on exertion since 10 days.No PND,Orthopnea. PAST HI
Read more

55yr old with aspiration pneumonia and Parkinsonism

Image
 June 20,2022 Hi, I am Ananya Nayak, 3rd sem medical 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 portfolio. A 55 year old male patient,farmer by occupation resident of Nalgonda came to the casuality with the complaints of Shortness of breath and fever 6 days ago.  HISTORY OF PRESENT ILLNESS- The patient was apparently asymptomatic 10 days back.Then he developed shortness of breath and he was unable to eat and drink anything properly. He was diagnosed with Aspiration Pneumonia and Pulmonary Kochs. Onset-insidious Gradually progressive Fever-on and off since 10 days,not associated with chills and rigor ,relieved on medication.  Cough-since 6 months A significant weight loss is seen and loss of appetite. No case of chest pain,chest tightness,dizziness. Ryles tube is used . At first, he was admitted in pulmonology department then he was transferred to General Medicine department as
Read more

General medicine elog

Image
1 July ,2022  33 yr old female with Moderate MR and severe PAH Hi, I am Ananya Nayak, 3rd sem medical 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 portfolio. A 33yr old female patient came who is a housewife and a resident of Bengal came to the OPD with chief complaints of Shortness of breath and bilateral  knee joint pain.She was admitted in the SS Ward on  HISTORY OF PRESENT ILLNESS-   The patient was apparently asymptomatic 2yrs back. Then she developed shortness of breath which gradually aggrevated on lifting heavy objects and exertion. 1 year back she developed bilateral knee joint pain which gradually aggrevated on exertion and subsided at rest. Onset-insidious  The pain was progressive for which she went to a hospital in Bengal and was treated conservatively.It subsided after taking medications but after the medications were over the symptoms reappeared.  2 months ago,pati
Read more