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.

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 smoking since 20years.

Family History:

Not significant 

General physical examination:

Patient is conscious ,coherent,cooperative and well oriented to time, place and person.

Well built and nourished

Pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy:absent

Pedal edema:absent 



Vitals:

Temperature - 98*F

PR :- 98beats per minute 

BP :- 130/100mm Hg

RR:-18 cycles per minute

Systemic examination:

Per Abdomen:

Shape of abdomen-distended
Umbilicus -inverted
Abdomen moves accordingly with respiration.
No sinuses/scars
Swelling in left lumber region
Abdomen is soft,tenderness in bilateral loin region.
Lipoma measuring 6x4x3cm associated with pain.
No free fluid
No organomegaly
Bowel sounds- present 

Cardiovascular system: 

Inspection-
Shape of chest-Normal  
No precordial bulge.
No dialated veins,scars and discharging sinuses.
No visible pulsations.

Palpation-

Apical beat felt in 5th intercostal space.
No parasternal heave and thrills

Respiratory system:

-Inspection:

Trachea -appears to be central

Chest appears bilaterally symmetrical ,movements are symmetrical on both sides.

elliptical in shape.

No chest wall defects.

No scars and sinuses.


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