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.



         
                                  


                      
                      
                       
                        
                        
                     
                                     
                        
                                             
                                 .

                        
                         
         
                          
                      
             









      

Comments

Post a Comment

Popular posts from this blog

General medicine

Image
 Hi, I’m A Naga pravallika 3rd Sem medical student.Thjs is an online e-log book to discuss our patient health data.This also reflects my patient centered online learning portfolio  An 47 year old women,tailor by occupation,resident of Nalgonda was admitted in the hospital on 2/6/22(Tue) with complaints of fever , body pains , loss of appetite. 10 years back she developed joint pains she was treated at private hospital asymptomatic until 8 months back.post covid vaccine she was treated with medication.patient had a history of decreed vision at age of 15 years.  Patient history Diet-mixed Appetite-decresed Sleep-disturbed General Examination  Conscious Coherent Pallor No icterus No clubbing of fingers No lymphadenopathy  No edema  A rash was present on the face   
Read more

General medicine e-log 5

Image
 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 60 year old male patient came with cheif complaints of shivering of right arm and forearm since 2years    HOPI -                 Patient was apparently asymptomatic 2years back. He then developed shivering of right hand and forearm   Insidious onset and gradually progressive. Initially localised to fingers and later radiated to right arm  C/O- numbness , tingling          Pain & Tingling in the right thigh          Shivering is present throughout the day intensity increases and decreases. PAST HISTORY -                             No history of trauma or injury in the past           N/ K/C/O- diabetes ,BP, TB ,epilepsy. FAMILY HISTORY -                                    No significant family history  PERSONAL HISTORY -                       Appetite - normal                              Sleep-adequat
Read more

General medicine e-log 4

 Hi, I’m A Naga pravallika 6th Sem medical student.Thjs is an online e-log book to discuss our patient health data.This also reflects my patient centered online learning portfolio     A 55 year old male patient came to causality with cheif complaints of cough associated with pain in the left side chest pain since 10 days.   HOPI-            Patient was apparently asymptomatic since 15 days and then developed fever since 10days.   FEVER- intermittent                    Low grade fever                    Not associated with chills and rigor    Associated with COUGH - since 10 days                                              Productive cough with white color, non-foul smelling sputum  Cough is associated with Left side chest pain since -     PAIN-non radiating                   Not associated with sweating  Cough associated with SHORTNESS OF BREATH since 10 days  NEGATIVE HISTORY                                    No history of burning micturition& loose stools   No history of hypert
Read more