Hi, I am Manasvi Peddineni, 3rd sem medical student.This is an online elog book to discuss our patients health data after taking their consent. This also reflects my patient centered online learning portfolio.
Ultrasound on 21/08/22:
Temperature Regulation Graph:
Case Scenario:
A 50 year old woman came to the hospital with history of fever and loose stools since 4 days.
Chief Complaint:
- fever since 4 days, which has diurnal variation and increases at night
- 6 episodes loose stools since 4 days, devoid of visible blood, and has mucous
- swelling of both lower limbs since 3 days
History of Present Illness:
- history of constipation since 2 years and stools are passed once every 3 days
- no shortness of breath
History of Past Illness:
- not a known case of hypertension/ diabetes mellitus/ epilepsy/ CAD/ asthma/ thyroid disorders
Personal History:
- married
- normal appetite
- mixed diet
- regular bowels
- normal micturition
- no known allergies
- no known addictions
Family History:
- no diabetes mellitus
- no hypertension
- no heart disease
- no stroke
- no cancer
- no tuberculosis
- no asthma
- no other hereditary diseases
Menstrual History:
- menopause
Physical Examination:
- height: not taken
- weight: not taken
- BMI: not taken
- no pallor
- no icterus
- no cyanosis
- no clubbing of fingers
- no lymphadenopathy
- edema of feet: present
- no malnutrition
- no dehydration
Vitals:
- BP: 120/70 mm Hg
- Pulse: 97/ mins
- Respiration rate: 16/ min
- Temperature: afebrile
- SPO2: 91% at RA liters of O2
- GRBS: 101% mg
Systemic Examination
Cardiovascular System:
- no thrills
- cardiac sounds S1 and S2 heard
- no cardiac murmurs
Respiratory System:
- no dyspnea
- no wheeze
- trachea position: central
- breath sounds: vesicular
Abdomen:
- shape: scaphoid
- no tenderness
- no palpable mass
- no bruits
- no free fluid
- hernias orifices: normal
- liver: not palpable
- spleen : not palpable
- no bowel sounds
- genitals: normal
- speculum examination : normal
- PV examination : normal
- P/R examination : normal
Investigations:
Blood Grouping Test on 20/08/2022:
Hemogram on 20/08/2022:
2D Echo on 21/08/22:
ECG on 21/08/22:
Treatment: