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.
Renal Function Test:
Complete Urine Examination:
Liver Function Test:
Temperature Regulation Graph:
Case Scenario:
A 19 year old female has come to the hospital on August 24th with chief complaint of fever and cough since 1 week. She is a known case of SLE (Systemic Lupus Erythematosus)
Chief Complaint:
- fever since 10 days, on and off, not relieved by medication
- cough since 10 days
History of Present Illness:
- patient was apparently asymptomatic 7 months back, when she had fever associated with joint pains and swelling, which was diagnosed to be SLE
- now, she has complaint of continuous high grade fever since 10 days, with no diurnal variation
- no history of vomiting, diarrhea or burning micturition
History of Past Illness:
- not a known case of hypertension / diabetes mellitus/ epilepsy/ CAD/ asthma / thyroid disorders
Personal History:
- not married
- occupation: student
- 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
Physical Examination:
- height: not taken
- weight: not taken
- BMI: not taken
- no pallor
- no icterus
- no cyanosis
- no clubbing of fingers
- no lymphadenopathy
- no edema of feet
- no malnutrition
- no dehydration
Vitals:
- BP: 110/80 mm Hg
- Pulse: 83/min
- Respiratory Rate: 19/min
- Temperature: 104°F
- SPO2: 98% at RA liters of O2
- GRBS: 102% 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
- P/R examination : normal
Central Nervous System:
- conscious
- normal speech
- no neck stiffness
- no Kerning's sign
- cranial nerves: normal
- sensory : normal
- motor: normal
- reflexes: all present bilaterally
- finger nose in coordination: normal
- knee heel in coordination: normal
- gait: normal
Investigations:
Hemogram:
Treatment:
