General medicine E-log 2
Hi , I am Harsha Chandana ,3rd semester student. This is an online elog book to discuss our patients health data after taking his consent. This also reflects my patient centered online learning portfolio.
A 40yr old woman who works in a glass company was admitted in to the hospital on 31st of may with the chief complaints of
-joint pains since 1 year
-swelling in the abdomen and swelling in the legs since 1 year
-rashes on her entire body since 1 year
History of presenting illness:
Patient has been visiting local hospitals for the above mentioned complaints but the treatment was ineffective.The patient had fever for 4-5days and had vomited for 3 times after her admission into the hospital.Her vomit did not contain any food particles.The patient also had reduced urine output and reduced appetite along with SOB.
Past history:
No history of diabetes or hypertension.
Personal history:
No addictions
Mixed diet
Adequate sleep
Family history:
Nil
General examination:
Patient is conscious, coherent, cooperative Slight pallor, no icterus, cyanosis, clubbing or lymphadenopathy.
Vitals:
BP:110/80
PR:90bpm
TEMP:98.5 F
Report and Medication:
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