General medicine e-log 9

 of Hi, I am A.Naga pravallika ,5th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.


This is an ongoing case. I am in the process of updating and editing this ELOG as and when required


 * This is an ongoing case. I am in the Chief Complaints:

A 20 yrs old male came to opd with chief complaints of Yellowsish discoloration of eyes

HOPI:

patient was apparently asymptimatic since one year back then developed Yellowsish discoloration of eyes 

POSITIVE HISTORY

Loss of appetite

Irregular bowel and bladder movements

Adipsia

NEGATIVE HISTORY:

N/K/C/O: TB , Asthma, epilepsy, thyroid

PERSONAL HISTORY:

Mixed diet

Irregular bowel and bladder movements

Adipsia

No addictions

Sleep adequate

FAMILY HISTORY:

No relevent family history


GENERAL EXAMINATION:

The patient was conscious, coherent , well oriented to time place person and was examined in a well ventilated room

No pallor

Icterus present

No lymphadenopathy

No clubbing of fingers

Well built 

Well nourished

No pedal edema

VITALS:

Temperature :afebrile

Pulse:86bpm

Bp:100/70 mmhg


SYSTEMIC EXAMINATION 

RESPIRATORY SYSTEM

Position of trachea: central 

No dyspnea

No wheeze

Breathe sounds :vesicular


CVS:

S1 and s2 are heard

No thrills 

No cardiac murmers


CENTRAL NERVOUS SYSTEM

Conscious

No neck stiffness 

No kernick sign

Speech normal


Tone                 Rt                  Lt

UL                     N                   N

LL                      N                   N


Power               Rt                  Lt


UL                    5/5                 5/5

LL                     5/5                 4/5


PROVISIONAL DIAGNOSIS:

Patient was diagnosed with 2' jaundice










Loss of appetite
Irregular bowel and bladder movements
 HISTORY







:
N/K/C/O: TB , Asthma, epilepsy, thyroid
PERSONAL HISTORY:
Mixed diet
Irregular bowel and bladder movements
Adipsia
No addictions
Sleep adequate
FAMILY HISTORY:
No relevent family history
SYSTEMIC EXAMINATION
CENTRAL NERVOUS SYSTEM
Conscious
No neck stiffness 
No kernick sign
Speech normal

Tone                 Rt                  Lt

UL                     N                   N

LL                      N                   N


Power               Rt                  Lt


UL                    5/5                 5/5

LL                     5/5                 4/5

RRSPIRATORY SYSTEM

Position of trachea: central 

No dyspnea

No wheeze

Breathe sounds :vesicular

CVS:

S1 and s2 are heard

No thrills 

No cardiac murmers

GENERAL EXAMINATION:

The patient was conscious, coherent , well oriented to time place person and was examined in a well ventilated room

No pallor

Icterus 

HOPI:
patient was apparently asymptimatic since one year back then developed Yellowsish discoloration of eyes 
POSITIVE HISTORY
Loss of appetite
Irregular bowel and bladder movements
Adipsia
NEGATIVE HISTORY:
N/K/C/O: TB , Asthma, epilepsy, thyroid
PERSONAL HISTORY:
Mixed diet
Irregular bowel and bladder movements
Adipsia
No addictions
Sleep adequate
FAMILY HISTORY:
No relevent family history
SYSTEMIC EXAMINATION
CENTRAL NERVOUS SYSTEM
Conscious
No neck stiffness 
No kernick sign
Speech normal

Tone                 Rt                  Lt

UL                     N                   N

LL                      N                   N


Power               Rt                  Lt


UL                    5/5                 5/5

LL                     5/5                 4/5

RRSPIRATORY SYSTEM

Position of trachea: central 

No dyspnea

No wheeze

Breathe sounds :vesicular

CVS:

S1 and s2 are heard

No thrills 

No cardiac murmers

GENERAL EXAMINATION:

The patient was conscious, coherent , well oriented to time place person and was examined in a well ventilated room

No pallor

Icterus present

No lymphadenopathy

No clubbing of fingers

Well built 

Well nourished

No pedal edema

VITALS:

Temperature :afebrile

Pulse:86bpm

Bp:100/70 mmhg 20 yrs old male came to opd with chief complaints of Yellowsish discoloration of eyes
HOPI:
patient was apparently asymptimatic since one year back then developed Yellowsish discoloration of eyes 
POSITIVE HISTORY
Loss of appetite
Irregular bowel and bladder movements
Adipsia
NEGATIVE HISTORY:
N/K/C/O: TB , Asthma, epilepsy, thyroid
PERSONAL HISTORY:
Mixed diet
Irregular bowel and bladder movements
Adipsia
No addictions
Sleep adequate
FAMILY HISTORY:
No relevent family history
SYSTEMIC EXAMINATION
CENTRAL NERVOUS SYSTEM
Conscious
No neck stiffness 
No kernick sign
Speech normal

Tone                 Rt                  Lt

UL                     N                   N

LL                      N                   N


Power               Rt                  Lt


UL                    5/5                 5/5

LL                     5/5                 4/5

RRSPIRATORY SYSTEM

Position of trachea: central 

No dyspnea

No wheeze

Breathe sounds :vesicular

CVS:

S1 and s2 are heard

No thrills 

No cardiac murmers

GENERAL EXAMINATION:

The patient was conscious, coherent , well oriented to time place person and was examined in a well ventilated room

No pallor

Icterus present

No lymphadenopathy

No clubbing of fingers

Well built 

Well nourished

No pedal edema

VITALS:

Temperature :afebrile

Pulse:86bpm

Bp:100/70 mmhg

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