GENERAL MEDICINE elog 1

 Hi , I am Saranya ,3rd semester 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 portfolios


A 26 year old female daily wage worker by occupation resident of narketpally came to causality with complaints of fever and abdominal pain 6 days back on 2nd june.

HISTORY OF PRESENT ILLNESSES

Suffering from lower abdominal pain since 10 days and fever since 5 days relieving by medication

PAST HISTORY

Epigastric abdominal pain 
Normal mituration
No constipation
No chest palpitations

TREATMENT HISTORY

7 years ago mitral valve replacement surgery
No diabetes
No hypertension

PERSONAL HISTORY

Normal apitite
Regular bowels
Normal mituration
No drug use

FAMILY HISTORY

No hypertension
No diabetes
No heart disease
No cancers 
No asthma

GENERAL EXAMINATION
 
Pulse rate : 96 per minute 
Respiratory rate : 18/min
B.p : 140 / 80 
Spo :99%

SYSTEMIC EXAMINATION

 CVS
NO thrills
S1 ,S2 present

RESPIRATORY SYSTEM
NO dyspenoea
No wheezing
Central position of trachea

ABDOMEN
Scaphoid shape of abdomen
No palpable mass
No hernial orifices
No bruits
No free fluids
Bowel sounds heard
No palpable liver and spleen

CNS
Patient is Alert
Normal speech
No neck stiffness

 PROVISIONAL DIAGNOSIS
 Acute polynephritis

CLINICAL DIAGNOSIS




















MEDICATIONS 








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    Hi , I am Saranya ,3rd semester 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 portfolios A 26 year old female daily wage worker by occupation resident of narketpally came to causality with complaints of fever and abdominal pain 6 days back on 2nd june. HISTORY OF PRESENT ILLNESSES Suffering from lower abdominal pain since 10 days and fever since 5 days relieving by medication PAST HISTORY Epigastric abdominal pain  Normal mituration No constipation No chest palpitations TREATMENT HISTORY 7 years ago mitral valve replacement surgery No diabetes No hypertension PERSONAL HISTORY Normal apitite Regular bowels Normal mituration No drug use FAMILY HISTORY No hypertension No diabetes No heart disease No cancers  No asthma GENERAL EXAMINATION   Pulse rate : 96 per minute  Respiratory rate : 18/min B.p : 140 / 80  Spo :99% SYSTEMIC EXAMINATION  CVS NO thrills S1 ,S2 present RESPIRAT
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