1st Internals Assessment


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1801006084-LONG CASE

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This is an online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This E-log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment. A 30 yr old female resident of Choutuppal daily wage labour by occupation presented to the OPD with chief complaints of generalised weakness since last month , stomach pain from last 4 days and vomiting from the last 2-3 days. HISTORY OF PRESENTING ILLNESS- Patient was apparently asymptomatic 1 month ago then she developed fever which was sudden in onset and intermittent and was relived on medication(PCM) not associated with chills and rigirs she also had vomiting which was non blood stained bilious and projectile...
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83 yr old male with left sided upper and lower limb weakness and right side deviation of mouth

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A 83 yr old male patient came with the chief complaint of left lower limb weakness since yesterday morning  Complaint of left upper limb weakness since25 days Complaint ofright side deviation of mouth since yesterday morning  HOPI: patient was apparently asymptomatic 25days agothen he had left upper limb weakness which was sudden in onset gradually progressive(from distal to proximal for which he used herbal medication No c/o headache, vomiting , blurring of vision ,diplopia H/o left upper limb weakness 5 yrs ago for which he used herbal medication  H/o of RTA 4yrs ago rt upper limb and left shoulder fracture  H/o pulmonary TB 3 yrs ago on ATT for 6 months  Not a k/c/o HTN,DM,CAD, epilepsy  GENERAL EXAMINATION:- Patient is conscious , coherent & co-operative Well built and nourished. No signs of pallor, icterus, clubbing, cyanosis, pedal edema and lymphadenopathy. Vitals @ admission  Temp - 99.2F RR -...
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60 YR OLD MALE WITH FEVER COUGH AND PAIN IN MULTIPLE SMALL JOINTS

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A 60 yr old male came to the OPD with chief complaints of  .Fever since 10days .pain in multiple joints of hand from past 2 yrs .pedal edema since 15 days HOPI:patient was apparently asymptomatic 2 yrs back then he had multiple joint pains( both hands metacarpophalangeal joints and both knee joints.joint restriction present . morning stiffness present c/o lower limb swelling since 1 yr pitting type till ankle H/o trauma to left leg middle toe 1 month back No c/o cough No c/o decreased urine output  H/o chronic NASID abuse since 1 yr for joint pain Past history:N/k/c/o HTN DM TB CVA CAD Asthma epilepsy  Family history:Not significant  Personal History   Diet:mixed   Appetite:decreased   Sleep:aquate   Bowel irregular and bladder: normal   No addictions     General Physical Examination   Patient is conscious coherent and cooperative     Moderately built and moderately nourished           ...
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