Posts

A 14 years old girl came to the opd withfever since 5 days.

Image
  Chief complaints: fever since 5 days History of present illness: Patient was apparently asymptomatic 5 days back then she developed fever. Fever was associated with body pains and subsided after medication. The temperature used to rise in the nights. Patient developed cough since 2 days.  Past history: No similar complaints in the past  Personal history:  Diet: mixed Appetite: normal  Sleep: adequate  Bowel and bladder: regular  Addictions: none Family history: not significant  General physical examination:  Patient is conscious, coherent and Cooperative, well oriented to time place and person. Moderately built and nourished. Vitals :  BP: Pulse rate:  Respiratory rate: 16 Temperature: afebrile  Pallor: present ( very pale)   Icterus: absent  Cyanosis: absent  Clubbing: absent  Lymphadenopathy: absent Edema : absent  Systemic exam...

A 36 year old male presented to opd with seizures.

Image
  History of present illness: On 24th a 36 years old male patient cable operator by occupation presented to general medicine opd with seizures at 3am. The patient was apparently asymptomatic until 2am then he developed seizures which occurred in 4 episodes with an interval of 5-10 minutes, each episode lasting for 2 minutes, without postictal confusion. The seizures were generalized and with vigorous contractions and relaxations. Just before the occurrence of 1st episode patient experienced tightening of muscles in the limbs and lifting of the lower limbs. 3 years back he was diagnosed with diabetes type 2 and is on medication. When RBS was done immediately after he came to hospital it was 559 and the BP was 160/100 mm Hg.  Past history: No similar complains in the past. In 2019 there was mild head trauma and swelling which subsided after 3 days. Not a known case of Hypertension, Asthma, thyroid, epilepsy. Personal history: Patient is a cable operator by occupation. He wakes u...

29 year old male post renal transplant renal failure.

Image
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. On 7th February a 29 year old male resident of west bengal computer technician by occupation came to General medicine opd for a regular checkup after live renal transplant in April 2021, reports ended up showin...

A 75 year old female with burning micturition and altered sensorium (Type 2 DM since 4 yers and Hypertension since 3years)

Image
History of present Illness:  75 years old female presented to General medicine department with chief complaints of burning micturition since 6 months,shivering and decreased responsiveness since yesterday morning .  Patient was apparently asymptomatic 4years back then she had a fall from stairs and got her knee injured which later got ulcerated and grafting was done, then she was diagnosed with diabetes mellitus. 3years ago she had an episode of giddiness and was diagnosed with hypertension.  3 years back she had a low back ache and was diagnosed with some kidney problem ,2 years back she had chest pain and was diagnosed with heart problem? And using medication regularly. H/o slight involuntary movements of hands. No h/o fever , headache, neck stiffness. No h/o head/ spine trauma No h/o loss of consciousness, vertigo, tinnitus.  Past history : DM - 4years                          Hypertension- 3years...