GENERAL MEDICINE ASSIGNMENT

 Date of admission -  Chief complaints :  A 15 year old male patient resident of poddichedu presented to the opd with chief complaints of  1) chapping of corner of lips since 3 months  2) inflammation of lower lip since 3 months History of present illness :  Patient was apparently asymptomatic 3 months ago and then he developed chapping of the corner of the lips which was insidious in onset and he is intolerable to spicy food and is aggravated by cold weather .  History of past illness :  Not a K/C/O of DM , HTN , epilepsy , asthma .  Treatment history :  Personal history :  Diet - mixed  Appetite - reduced  Sleep - normal  Bowel and bladder - regular  Patient wakes up around 7 am in the morning and has a good amount of breakfast fil Family history:  Not significant  O/E: PT IS C C C BP: 100/70 MMHg  PR :84 BPM RR: 18 CPM SPO2: 98% AT ROOM TEMP NO SIGNS OF PALLOR ICTERUS CLUBBING CYANOSIS LYMPHADENOPATHY S/E: CVS: S12 PRESENT CNS: NAD RS: NVBS HEARD Physical examination :  Investigatio

 Date of admission - 11/09/2023 Chief complaints :  A male patient of age 77 years old resident of vangamuthy presented to the opd with chief complaints of  1) diminution of vision in both eyes since 2 years  History of presenting illness :   Patient was apparently asymptomatic 2 months ago and he developed diminution of vision which was insidious in onset and gradually progressive in nature .  It was not associated with watering , photophobia , redness or itching .  History of past illness : There was a history of surgery related to CHD 1 year ago  There was a history of auditory and visual hallucinations since 1 year and was diagnosed 1 month ago . K/C/O of DM 2 since months  Not K/C/O of asthma , epilepsy , Tb  Treatment history :   1)  Metformin 500 mg  2) risperidone 2 mg  Personal history :  Sleep : inadequate  Appetite : loss of appetite  Bladder and bowel : regular  Drug allergies : no  Addictions : no  Family history :  Not significant Physical examination :   1) general exami

 Date of admission - 02/09/2023 CHIEF COMPLAINTS : A 65 year old male patient presented to the opd with chief complaint loss of consciousness which was associated with sweating .  There was no history of nausea , vomiting , pain abdomen, headache and burning micturition .  HISTORY OF PRESENT ILLNESS  :  Patient was apparently asymptomatic 15 days ago and then he had and incident of thorn prick in the right leg and he visited the local hospital where they had incised and removed the thorn and then the swelling in the right increased and there was blister formation in the right leg and he was referred to higher centres where they diagnosed him to have high Creatine levels and then was referred to another higher centre where haemodialysis was done and debridement of the blisters were done .  After being discharged from the hospital he lost consciousness and was admitted to our hospital .  HISTORY OF PAST ILLNESS :  K/C/O DM 2 since 10 years  Was on medication s NIK/CIO HTN, TB, EPILEPSY,

  DATE OF ADMISSION - 22/06/22 CHIEF COMPLAINTS - 45 yr old female came to OPD with chief complaints of swollen legs,leg pain,distended abdomen. HISTORY OF PRESENT ILLNESS  -C/O abdominal distension since 2months - pedal edema and shortness of breath since 2months. -k/o decreased appetite and loss of weight. HISTORY OF PAST ILLNESS   k/c/o DM and on INJ mixtard insulin k/c/o hypothyroidism and on T.Thyronorm k/c/o HTN and on T.Telma. TREATMENT HISTORY k/c/o DM,HTN Not a k/c/o CAD,TB,asthma,chemo,radiation and blood transfusion. PERSONAL HISTORY Mixed diet Appetite Normal Sleep adequate Bowel and Bladder movements regular. FAMILY HISTORY Not significant  PHYSICAL EXAMINATION Temp- afebrile BP-130/70 mm hg Pulse rate-98/min Respiratory rate-22/min Spo2-98% GRBS-540mg% -No signs of pallor,cyanosis,lymphadenopathy,icterus. SYSTEMIC EXAMINATION  CARDIOVASCULAR SYSTEM • S1, S2 heard • No murmurs RESPIRATORY SYSTEM: • NVBS heard •Position of trachea - central •Breath sounds - vesicular ABDOME

 A 51 year old female who is a labourer by occupation  presented to the opd with chief c/o of loose stools , bloating , stomach pain and dry mouth since 10 days .  CHIEF C/O :  1) loose stools  2 ) vomitings  3).stomach pain since 10 days  H/O PAST ILLNESS :  1) N/k/C/o of HTN, DM , TB , CAD , epilepsy  H/O of PRESENT ILLNESS :    No complaints of burning micturition   No complaints of blood in stools    No complaints of fever  TREATMENT HISTORY :      Saline was infused       Tablets for motions and stomach pain were given  PERSONAL HISTORY :      Loss of appetite       Alc consumption- no        Smoking - no         Toddy - drank toddy in summer for 20 days   FAMILY HISTORY :        Nothing significant    PHYSICAL EXAMINATION :  > GENERAL EXAMINATION     No pallor , no cyanosis , no icterus , no lymphadenopathy, no clubbing , dehydration present, no oedema  1) VITALS :       Temp - 98.8 F        Pulse rate - 114/min        Respiratory rate - 20 / min        Bp - 130/100 mm/Hg    

45YR FEMALE WITH FEVER, VOMITINGS AND SHORTNESS OF BREATH  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 patient's clinical problems with collective current best evidence based inputs.  This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.” I've 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 a diagnosis and treatment plan. A 45year female Presented with  C/O Fever since 5 days C/O Vomitings since 4 days C/O Headache since 4 days C/O Shortness