45yrs old male patient

This is an online E Log book recorded to discuss and comprehend our patient's  de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.

Shreshta.A  06
Aswin.I  18


Chief complaints :

A 45 year old male driver from nalgonda was admitted in the hospital on 14th june 2022
with chief complaints of
Itching sensation throughout the body and Pain in the right abdominal region since 1month.

History of present illness:

Patient was apparently asymptomatic 1month back, then he developed multiple lesions over lower limb. Lesions progressed to form ulcers.
SOB present since 1month 
Increase thrist and urine output (14 to 15 episodes of mixturation),increase bowel movements since 1week
Frequently coughing (sputum) while talking
Fever: persisting since 1 week
            Chills and rigor 
            Cough and cold
Felling nauseous.

Past history: 

Not diabetic 
No hypertension 
Did not undergo any surgery 
Not on any medications.


Family history:
Not relevant.

Personal history:

Khaini consumer since 10 years
Alcoholic since 20 years
Appetite: reduced 
Diet: mixed
Lack of sleep
Bowel/bladder: polyuria , increased bowel movements.


General examination:

Conscious, cooperative, coherent 
Moderately built
Moderately nourished 
Pallor present
No cyanosis
No icterus 
No lymphademnopathy.

Vitals:

BP 110/70
Pulse 80/min.

Treatment: 

Clinical images:

Reports: 


Comments

Popular posts from this blog

This is an online E Log book recorded to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.

A 20 YRS OLD MALE CAME TO OPD WITH CHIEF COMPLAINTS OF YELLOWISH DISCOLORATION OF EYES.