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General Medicine

25,August,2022.
E LOG GENERAL MEDICINE 

Hi, I am Pindi Gayatri , 3rd 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've 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.

 CHEIF COMPLAINTS:
Fever since 15 days, pain in the abdomen since 2 days, distension of abdomen since 2 days. 

HOPI:  ( Presenting) 
Patient admitted on 12th of august with high fever and convulsions. Apparently, she developed pain in the abdomen since 2 days along with distension of abdome

HOPI: (Past) 
No significant past illness

Personal history:
She is married and a daily wage worker. 
Appetite
Bowel
Micturition
Addictions:  she is a regular consumer of alcohol since 15 years. 
Positive history of toddy intake and bettle nut intake. 
Family history:


PHYSICAL EXAMINATION:
General examination-
Pallor not seen
Icterus not seen
Cyanosis not seen
Clubbing not seen
Clubbing of fingers and toes- absent
Lymphadenopath- absent
Edema of feet is- present

Vitals:
Bp-
Pulse rate-90 beats per min
Respiratory rate-
Spo2-99
Temperature-99.1 degree fahrenheit

SYSTEMIC Examination:
. Cvs
No thrills
S1s2 heard
No cardiac murmurs

. Respiratory examination



.Abdominal examination

Shape of abdomen- obese
Palpable mass not seen

CNS -
She is conscious
Incoherent speech is seen
No neck stiffness
In Cranial nerves, motor system, sensory system no abnormal detected(NAD). 


Investigations:


ECG:







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