General medicine e-log 7

 Hi, I’m A Naga pravallika 6th 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 


A 40 year old male patient came with cheif complaints of lower back pain since 3days 


HOPI- 

            Patient was apparently asymptomatic 15 days back then he got snake(viper) bite on left ring finger and went to local hospital and managed while working in the field then after 3days he developed lower back pain which is insidious in onset, intermittent,sharp pain ,non-radiating aggregated on lying in supine position associated with low grade fever ,nausea ,abdominal bloating 

No h/o - burning Micturition, increases or decrease urine output  

PAST HISTORY:

No complaints of chets pain,cough,cold,loose stools, vomiting,Not a known case of diabetes,asthma,tb,epilepsy

PERSONAL HISTORY:

diet-mixed

Appetite -reduced

Sleep-adequate

Bowel nd bladder normal

No additions

FAMILY HISTORY:

no relevant family history 

GENERAL EXAMINATION:

Patient was conscious coherent well oriented to time place and person

No pallor,icterus,clubbing,cyanosis, lymphadenopathy,

Temperature-afebrile

Pulse-94beats /min





SYSTEMIC EXAMINATION


Cardiovascular system 

No thrills 
No cardiac murmurs
Cardiac sounds: S1 and S2 heard


Respiratory system

dyspnea absent 
No wheezing
No Vesicular breath sounds .
Position of trachea - central


Abdomen

Abdomen is distended 
No tenderness
Palpable mass -present 
Bowel sounds anew present 
No bruits
No free fluids


Central nervous system

Patient was conscious and coherent well oriented to time, space and person

Speech is normal 
Cranial nerves normal 
Motor system normal 
Sensory system normal 
Glasgow scale normal 


REFLEXES



                                      Right.                       Left 



Biceps                             ++                           ++ 



Triceps                            ++                            ++



Supinator                        ++                             ++



Knee                                ++                             ++



Ankle                             ++                               ++



CEREBELLAR SIGNS 

finger nose coordination -no 

Knee heal coordination -no 



GAIT 


Normal.



         
                                  


                      
                      
                       
                        
                        
                     
                                     
                        
                                             
                                 .

                        
                         
         
                          
                      
             









      

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