2nd internal assessment

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5/10/21

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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
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Chapped lips

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 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
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Ascites

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  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
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