GENERAL MEDICINE E-log
K ARAVIND,9th sem,roll number 55
This elog depicts the patient -centered approach to learning . This is an online E log book recorded to discuss and comprehend our patients de-identified health data shared , after taking his /her /guardians signed informed consent . This elog also reflects patients centered learning portfolio.
CHEIF COMPLAINTS;
28 years male autodriver by occupation admitted in hospital with c/o fever since 5 days
HOPI:
patient was apparently asymptomatic 5 days back then he developed intermittent low grade fever a/w generalised body pains, headache, and giddiness. Lots of appetite, not a/w chills and rigor no diurnal variation
No history of malena, hematuria
No complaints of chest, pain, cough, cold
No complaints of burning micturition
No complaints of loose stools, nausea, vomiting
PAST HISTORY:
Not a known case of hypertension, diabetes, thyroid, CAD ,TB
PERSONAL HISTORY;
Appetite: normal
Diet: mixed
Addictions: no
Sleep: adequate
bowel movements regular
GENERAL EXAMINATION;
Pt is conscious, coherent, cooperative
No signs of clubbing, cyanosis, pallor ,icterus,lymphendenopathy
Vitals :
Bp :120/90mm hg
PR:78bpm
Temp:97.8
RR: 21 cpm
No precordial bulge.
-Inspection:
Trachea -appears to be central
Chest appears bilaterally symmetrical ,movements are symmetrical on both sides.
elliptical in shape.
No chest wall defects.
No scars and sinuses.
-Palpation:
All the inspectory findings are confirmed.
Trachea central
Supraclavicular N N
Infraclavicular N N
Mammary N N
Inframammary N N
Axillary N N
Infraaxillary N N
Suprascapular N N
Infrascapular N N
-Percussion Right Left
Supraclavicular R R
Infraclavicular R R
Mammary R R
Inframammary R R
Axillary R R
Infraaxillary R R
Suprascapular R R
Infrascapular R R
R-Resonant
-Auscultation Right Left
Supraclavicular NVBS NVBS
Infraclavicular NVBS NVBS
Mammary NVBS NVBS
Inframammary NVBS NVBS
Axillary NVBS NVBS
Infraaxillary NVBS NVBS
Suprascapular NVBS NVBS
Infrascapular NVBS NVBS
COMPLETE BLOOD PICTURE
Hemogram | 21/10/23 | 22/10/23 | 23/10/23 | 24/10/23 | 25/10/23 |
Hb | 19.1 | 17.5 | 16.8 | 15.6 | 15.2 |
TLC | 4000 | 4000 | 5200 | 5600 | 5600 |
RBC COUNT | 6.19 | 5.81 | 5.81 | 5.37 | 5.22 |
PLATELET COUNT | 18000 | 40000 | 20000 | 28000 | 52000 |
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