2nd internal assessment

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70 year old malec/c of low grade fever

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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 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". This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome.  I've 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 a diagnosis and treatment plan.   This is a case of a 70 year old female admitted in the ward, with a history of  low grade fever loss of appetite constipation.  History of presenting illness She presented with a...
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53 year old female patient c/c B/l loin pain

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53yrs old female patient presented with CHIEF COMPLIANTS of B/L Loin pain since 6days and decreased urine output since 4 days and SOB (Grade 2-3) since 3days HOPI Patient was apparently asymptomatic 6days back then she had B/L Loin pain since 6days(it started in lower back midline and radiated to groin region) and decresed urine output since 4 days and then she had SOB(Grade 2-3) since 3 days. Daily routine: She wakes up at 7am and does her daily chores and makes breakfast and have their breakfast at around 9am and takes rest for some time and then she used to do work like washing utensils and cleaning the work but when she was diagnosed with hypertension she stoped her work she just cooks and take rest for 2-3 hrs in the afternoon. PAST HISTORY she had similar complaints of loin pain 2months back for which she had given anti biotics and told to drink more water by local practioner in miryalaguda k/c/o Type 2 DM from 12 years and on OHA recently shifted to insulin injections and HTN fr...
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A 55yr old female complains of fever,decreased appetite , Breathlessness ,vomitings and loose stools.

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A 55yr old female complains of fever,decreased appetite since 1 month, Breathlessness since 1 week,vomitings and loose stools since 3 days. CHIEF COMPLAINTS: Pt complains of fever,decreased appetite since 1 month, Breathlessness since 1 week,vomitings and loose stools since 3 days.  HOPI : Patient was apparently asymptomatic 3 months back. Then she had multiple swellings in front of the left ear, for which she developed fever which was lowgrade, intermittent, no evening rise of temp, ass with decreased appetite since 1 month. She then had vomitings which was non bilious and non projectile, containing food particles. She had history of loose stools since 3 days, which is 4-5 episodes per day, watery in consistency.  Past history : K/c/o Hypertension since 7 years.  7 yrs back she had c/o giddiness for which she went to hospital and was found to have HTN.  Personal history: Diet- mixed Appetite-decreased Bowel and Bladder movements- ...
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