2nd internal assessment



 



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general medicine practicals

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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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE 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 Chief complaints : b/l pain in lower limbs upto knees since 20 days  B/l swelling in the leg since 20 days  HOPi : Pt was appently asymptomatic 3 yrs back then he developed sudden pain in right sid
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General medicine

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Ch Janani Roll no. 29 A female patient aged 74 yrs  came to the OPD with chief complaints of fever  ,shortness of breath ,and she had altered sensorium. Chief complaints Fever ( 7 days) Shortness of breath(4 days ) Altered sensorium ( 2-3 days) History of present illness Patient was apparently asymptomatic 10 days back and She was admitted to hospital by her family due to loss of consciousness,fever,loss of speech and altered sensorium. History of past illness N/k/c/o diabetes mellitus,CAD and CVA hypertension,TB, epilepsy,no previous surgeries. She is a known case of asthma using inhalers ( duration not known) Personal history She is married Diet : mixed Bowel and bladder movements: normal  Appetite: normal No allergies No addictions Drug history: used pain killers for pain and swelling of lower limbs General examination  Palor No cyanosis No icterus No clubbing of fingers Pedal edema present ( pitting type )  Moderately built No Lymphadenopathy Vitals   Temperature: afebrile Pulse ra
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case 1

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Ch Janani Roll no .29 A 28 yr female patient resident of Surat came to OPD with chief complaints of left side flank pain, shortness of breath and dysuria. Cheif complaint Left side flank pain Dyspnoea One episode of hematuria and dysuria History of present illness Patient was apparently asymptomatic 15yrs ( i.e in 2007 ) she had complaints of loss of weight and appetite for which she was diagnosed as pulmonary tuberculosis and on started on anti tubercular therapy .But she discontinued the treatment and she was kept of 8 months ATT.and in 2020 she developed low back ache for which she was diagnosed as renal calculi.now she came to our hospital with c/o left flank pain , dyspnoea grade 2,one episode of hematuria. History of past illness Hematuria,k/c/o tuberculosis in childhood No h/o of diabetes , hypertension, epilepsy and no previous surgeries. Personal history Married Appetite:normal  Diet : mixed  Bowels: irregular  Micturition:normal  Non alcoholic non smoker and no drug allergies
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