1st Internal Examination

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45 M with Abdominal distension and b/l lower limb swelling

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This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog 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 diagnosis and treatment plan. Unit 1  AMC bed 5 DOA:29/5/23 45 year old male ,lorry driver by occupation,resident of Nalgonda came to the opd with chief complaints of       Abdominal distension since 4-5 days     ...
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A 38 yr old female came to OPD with fever, vomiting and not able to walk..

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  A 38 yr old female patient sweeper in a fertiliser company by occupation brought to casualilty with fever and vomitings and hypersalivation. She had low grade, intermittent fever which relieves on medication not associated with chills and rigors. HOPI: She had 5 episodes of vomitings for 2 days which contained food particles, non projectile and non foul smelling. She needed support for walking. Fever since 3 days, vomitings 5 episodes(12th & 13th June 2022), unable to walk since 2 days Negative history: no history of shortness of breath, cough, loose stools Past illness- known hypertensive since 2 years (using medication) NOT a known case of DM, asthma, tuberculosis, diabetes, asthma, epilepsy, CAD Personal History: Mixed diet Bowel And Bladder-Regular   Sleep Adequate  No Allergies And Addictions. Family History: not significant  General Examination:  Patient is Conscious,  Moderately Built and Nourished. Pallor Absent Icterus Absent Clubbing Ab...
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Chief complints- A 4yrs old female child Was brought by mother with the complaints of cough :: 7days History of Presenting illness: child was apparently asymptomatic 7days back then developed cough which was Productive type, diurnal variation Present, gradually progressive more during the night time associated with post tussive vomiting. It is associated with nasal discharge noisy breathing, not associated with mouth breathing H/o fever  5 days back for 3 days which was gradual in onset, low grade, intermitta not associated with rigors; aggrevates durine night time , relieved on taking medication Past History  H/o nasal discharge at 3 months of age. Shown to local RMP , where symptomatic and supportive treatment was given and symptoms subsided. No documentation available Antenatal History -conceived spontaneously after 9 months of married life Natal History Full term, LSCS  BT WT 2.5kg cried immediately after birth Breast fed within 24 hours of delivery . POST NATAL HIS...
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