GENERAL MEDICINE E-LOG 3
20/6/22
Hi, I’m A Naga pravallika 3rd Sem medical student.This is an online e-log book to discuss our patient health data.This also reflects my patient centered online learning portfolio
An 40 year old women,housewife,resident of kammareddygudem,was admitted to the hospital on18/6/22(Saturday).
CHEIF COMPLAINTS:
Pain on the left side of the head,neck,arm,limb.
Low urine output
Burning micturition
2years back she had pain on the left side of her head,arm,limb.she visited a private hospital they gave her medication.she use them for 2-3 months but still the pain is not subsided so,she discontinued her medications .
She had a pain at loin since, 2years.USG showed partially distended urinary bladder and irregular bladder wall thickening .CUE showed 3-4 pus cells.
She was diabetic since 2years.she had pain in the ear since 1year and the pus comes out every 2-3days no pain but she had ictching when the pus comes out.
PERSONAL HISTORY:
Appetite-normal
Diet-mixed
Bowels-regular
Allergy-yes
FAMILY HISTORY:
Diabetic-both parents
No hypertension
No heart disease
GENERAL EXAMINATION:
Pulse rate -80bpm
Bp-120/80mm hg
CNS-s1,s2+
Hb-11.5
NEGATIVE HISTORY:
No cough
No fever
No bp
No itching at urethral region
No history of white discharge
MENSTRUAL HISTORY:
Present cycle1/30
Regular,pain,no clots.
Last menstrual cycle 4/30, regular, pain,no clots.
P/A-obese,soft,non-tender
On palpitation no visible lesion
Serology positive for HIV.
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