General medicine e-log-1

 Hi, I am anirudh manne 3rd sem medical 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 42 year old male daily wage worker by occupation resident of narketpally came to causality with  complaints of pyrexia and presence of swellings 10 days back on 31st May.

 

Past history

The patient is a known case of tuberculosis few months back

No similar complaints in the past 

Not a known case of asthma, diabetes, epilepsy, cardiac disease, hypertension

Present history

Diet : mixed

Appetite: normal

Sleep :normal

No allergies

Family history

No significant family history

General examination 

Patient is concious, coherent, cooperative

Presence of lymphadenopathy in his neck and abdomen region

No cyanosis 

No pallor

No icterus 

No clubbing of fingers 

No poedal odema 


Systemic examination

Respiratory:

no swellings

B/L symmetrical chest 

skin normal 

no sinuses 

no drooping of shoulder

no tenderness

trachea central in position 

CVS : 

s1,s2 heard
No additional sounds were heard
GIT : 
Soft
Tender in abdomen region near the swellings


CNS :

Dominance - Right 


 • conscious


 • memory - able to recognize his wife beside him


 • Speech - normal

 

Motor system

His motor system was tested and found to be normal


Provisional diagnosis


Cervical and abdominal lymphadenopathy 



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