GENERAL MEDICINE E-log

NAME:A sanvith

ROLL NO:09 

Welcome and greetings to every one who are visiting my blog. This is A sanvith of 8th semester. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.

CHIEF COMPLAINTS:

Generalized weakness since 1year

Premature ejaculation since 1year.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 1year back and then he developed weakness associated with semen in urine. And also developed polyuria(nocturia two to three times at night) patient also history has h/o premature ejaculation 2-3minutes since 1year.

HISTORY OF PAST ILLNESS:

 Patient was n/k/c/o go fever, pain abdomen, burning micturition, vomitings,loose stools.

N/k/c/o chest pain, palbitations, shortness of breath, Orthopnoea,PND.

Not a K/lo HTN,DM, CAD, CVA, thyroid disordes

epilepry.

TREATMENT HISTORY: 

No treatment history 

PERSONAL HISTORY:

Diet: mixed

Sleep : adequate 

Appetite: normal

Bowel and bladder: Regular

FAMILY HISTORY:

Not significant

GENERAL EXAMINATION:

Patient was consious coherent and cooperative and well oriented to time and place.

Well nourished and moderately built.

No history of pallor, icterus, clubbing, cyanosis, lymphadenopathy and oedema.

VITALS:

Temperature: 98.6F 

Bp:124/78

PR:76bpm

RR:16cpm

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM

•S1, S2 heard

RESPIRATORY SYSTEM:

•NVBS heard

•Position of trachea - central

•Breath sounds - vesicular

ABDOMEN

•Shape - obese

•No Tenderness

•No palpable mass

 -No fluid present.

-No palpable liver or spleen

CENTRAL NERVOUS SYSTEM:

•Intact

•No focal defect

•No abnormality detected

CEREBRAL SIGNS

• No finger nose incordination

•No knee heel incordination.

INVESTIGATION:

BLOOD SUGAR- FASTING

BLOOD UREA

SERUM ELECTROLYTES

HBsAg

ANTI HCV ANTIBODIES

HIV 1/2

ULTRASOUND REPORT

PROVISIONAL DIAGNOSIS:

Generalized weakness?