Nikitha Edam roll no:48

 JUNE july 30,2021 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 individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. MONTHLY SUMMATIVE ASSESSMENT I have been given the following questions to answer in an attmept 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 diagnosis and come up with a treatment, to assess the quality of treatment given and to suggest improvisations.   Question 1: Competency tested for Peer to peer review and assessment : After going through one particular answer of ten students in this l https://generalmedicinedepartment.blogspot.com/

 A 45 year old female , an agricultural labour by occupation came to the casualty with the  chief complaints of- •fever since 1 month  •facial puffiness since 9 days •decreased urine output since 6 days  •vomiting since 2-3 days HOPI– The patient was apparently asymptomatic one month back and then developed fever,Which was high-grade, associated with chills, and was taken to a local hospital and  got treated. Along with fever, she had loss of appetite and loss of taste. Fever subsided for one day and then she developed it again. She visited the hospital after 15 days, Where they advised her to consult a gynaecologist as she had her last LMP2 years back She never had any complaints of pain abdomen Then, she consulted a gynaecologist, and the doctor advised her USG for the localisation of infection. The USG revealed a right ovarian cyst. Along with USG ,haemogram, RFT, LFT were done. RFT showed all  the values Within the normal range with creatinine being around 0.9-1 ,Haemoglobin was no

 A 40 year old female came with the complaints of sudden onset of giddiness- 2 episodes on friday evening with no loss of consciousness and fits HOPI- The patient was apparently asymptomatic  8hrs    ago H/o weakness of left upper limb,lower limb, deviation of mouth to right since 8 hrs with slurred speech No h/o any tingling,numbness,headache No h/o fever C/o dragging of left leg while walking since 5 hrs PAST HISTORY- Not a k/c/o DM,HTN,CAD,epilepsy PERSONAL HISTORY- Sleep-adequate Appetite-normal Diet-mixed Bowel and bladder - regular Addictions- Consumes 1 bottle of toddy daily Tobacco chewer since 20 years FAMILY HISTORY- No significant family history GENERAL EXAMINATION- The patient is conscious,coherent and cooperative No pallor,icterus,cyanosis,clubbing,lymphadenopathy and pedal edema VITALS- PR-95 BP-140/90 mmHg Spo2-100% GRBS- 78 mg% SYSTEMIC EXAMINATION- CVS-  S1,S2 heard No thrills ,murmurs RESPIRATORY SYSTEM- BAE+ NVBS heard ABDOMEN- shape- normal No tenderness,palpable ma

 A 50 year old male came with c/o SOB since 1 hour,acute onset,grade 4,orthopnea + HOPI- The patient was apparently asymptomatic 6 years back then he developed SOB and went to a hospital where they performed 2D echo which showed heart failure with reduced ejection fraction(40%),he took the medicines for 1month and stopped as the SOB subsided 3 years ago, he had cough,breathlessness,fever and sputum for AFB is negative but was empirically started on ATT but used them only for 4 months and stopped,since then he had cough occasionally  HISTORY OF PAST ILLNESS- H/o inguinal hernia since 1 year(not operated) K/c/o DM since 4 years on T.Glimy m1 BD H/o old kochs -used ATT for 4 months,3 years ago H/o HFrEF since 6 years secondary  to ?CAD PERSONAL HISTORY- Diet-mixed Appetite-normal Bowel and bladder-regular Addictions-alcoholic since 30 years,consumes 90 ml daily  And smokes 20 cigarettes/day since 30 years FAMILY HISTORY- No relevant family history GENERAL EXAMINATION- patient is conscious

 A 31 year old male with chief complaints of pain abdomen since 1 week ,epigastric,non radiating,relieved by sitting,intermittent type C/o- vomitings since 1 week,4-5 episodes /day which lasted 3 days and subsided  C/o-SOB since 2 days,no c/o fever,chest pain,palpitations No c/o- decreased urine output No h/o- fever,loose stools No h/o-chest pain pedal edema HOPI- Pt.was admitted in outside hospital 1 week back,admitted for 1 week and treated with inj. Piptaz,inj.metrogyl,IVF .His creatinine kept on increasing so he was referred to our hospital Not a k/c/o DM,HTN,CAD,Epilepsy,TB PERSONAL HISTORY- Alcoholic since 4 years Consumes 180 ml daily and the last intake was one week back which was 360 ml Khaini+ GENERAL EXAMINATION- No pallor,icterus,cyanosis,clubbing,lymphadenopathy Pedal edema- present,pitting type PR-110/min RR- 26/min BP-150/100 mmHg Temp- SPO2-88% GRBS-104 mg% SYSTEMIC EXAMINATION- CVS- S1,S2 heard No thrills and murmurs RESPIRATORY SYSTEM- NVBS heard BAE+, decreased BS on

 A 18 year old male,from miryalaguda,who is a student, came to the hospital with chief complaints of low backache 1 week ago,fever since 5 days ,yellowish discolouration of eyes since 3 days ,vomitings (2 episodes) and loose stools(3 episodes)and blood tinged urine yesterday morning HISTORY OF PRESENT ILLNESS- Patient was apparently asymptomatic 6 months ago,then he noticed gradual loss of weight since 6months,patient had history of polyuria,nocturia,polydypsia since 2 months 10 days ago, patient attended a function outside and after 2 days he developed low backache and 2 episodes of vomitings and 3 episodes of loose stools for one day which subsided on its own. Next day,patient developed fever,intermittent,high grade,subsided with medication. Patient went to RMP and got treated for fever.patient noticed yellowish discolouration of eyes and urine 3 days ago.Nausea and loss of appetite + Burning micturition is present PAST HISTORY- No history of diabetes,asthma,TB ,epilepsy PERSONAL HIS