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

Hi I am, Aswin (roll no:18), 5th sem medical student. This is an online e-log book to discuss our patient's health data shared after taking his/her consent . This also reflects my patient centered care and online learning portfolio.

Chief Complaints:
A 20 yrs old male came to opd with chief complaints of Yellowsish discoloration of eyes.

History of presenting illness:
patient was apparently asymptimatic since one year back then developed Yellowsish discoloration of eyes 
POSITIVE HISTORY
Loss of appetite
Irregular bowel and bladder movements
Adipsia
NEGATIVE HISTORY:
N/K/C/O: TB , Asthma, epilepsy, thyroid

PERSONAL HISTORY:
Mixed diet
Irregular bowel and bladder movements
Adipsia
No addictions
Sleep adequate

FAMILY HISTORY:
No relevent family history

GENERAL EXAMINATION:
The patient was conscious, coherent , well oriented to time place person and was examined in a well ventilated room

No pallor
Icterus present
No lymphadenopathy
No clubbing of fingers
Well built 
Well nourished
No pedal edema

VITALS:

Temperature :afebrile

Pulse:86bpm

Bp:100/70 mmhg

SYSTEMIC EXAMINATION:
CENTRAL NERVOUS SYSTEM
Conscious
No neck stiffness 
No kernick sign
Speech normal

Tone         Rt         Lt

UL              N         N
LL              N          N

Power        Rt       Lt

UL              5/5   5/5
LL              5/5    4/5

RRSPIRATORY SYSTEM

Position of trachea: central 
No dyspnea
No wheeze
Breathe sounds :vesicular

CVS:

S1 and s2 are heard
No thrills 
No cardiac murmers
PROVISIONAL DIAGNOSIS:
Patient was diagnosed with 2' jaundice


Comments

Post a Comment

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.

Image
Hi, I Aswin.I 6th 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 protofolia Chief Complaints: Bilateral loin pain since 3days. History Of Presenting Illness: Patient was apparently asymptomatic 7days back then he sustained snake bite (with Russell viper) on left ring finger while working in the fields,visited local hospital and managed symptomatically.  C/O bilateral loin pain,insidious in onset ,intermittent,gradually progressive,pricking type ,non radiating,aggravates on lying down. C/O low grade fever,Nausea and vomiting,bloating. N/C/O Burning Micturation,decreased or increased urine output. N/C/O cough,cold,body aches,chest pain. Past History: n/k/c/o diabetes HTN,Epilepsy,Tuberculosis,CAD,CVA Personal History: Diet : Mixed,  Appetite : Normal Sleep : Normal Bowel and bladder moments :Regular  Addictions: chronic alcoholic since 20years. Tobacco smokin
Read more

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.

Image
Hi, I Aswin.I  6th 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 protofolia A 65 years old Male brought to hospital (Casualty) with   Cheif complaints * Right upper limb and lower limb weakness *Pain in neck History of presenting illness Patient was apparently asymptomatic till yesterday.Then he fall down over the floor on face(event occur around 5.30pm near miryaluguda and complaints of pain in neck (from 6.00pm on 10/10/23) sudden in onset and its not radiating and tenderness present on back of neck. Unable to move his right upper limb and lower limb. No micturition since fall •No history of nausea, vomiting,nose bleed,ear bleed •No history of fever Past history Not a known case of      Hypertension     Diabetes     Asthma     Tuberculosis     Epilepsy     H/o trauma (RTA) 10yrs back Personal history     Appetite normal     Mixed diet     Regular bowel movements  
Read more