General Medicine eblog

Hi I am Swetha, 6 th semester student.This is an online elog book to discuss our patient health data after taking his consent.This also reflect my patient centered online learning portfolio.

 39 F SLE ,ITP since 10 years diabetes since 6 years with generalised weakness since 1 week 

History of present illness: 
      Patient was apparently asymptomatic 1week ago then she developed generalised weakness which is gradually in onset 
Past history 
     known case of SLE since 10 yrs 
     DM since 6 yrs on medication 
             Glycomed gp
             HCQS 200 mg 
             Whysirol 5 mg 
   Not a known case of HTN , asthma, epilepsy, TB, CAD, CVD 
Family history:
      Irrevalent
 Personal history: 
       Diet : mixed 
      Appetite: normal 
      Bowel and bladder movement regular
      Sleep : adequate
      No addictions 
Menstrual history: 
    Length of cycle : 15 / 30 
    No of clothes per day : 2 
     Associate with clots but no pain
Vitals : 
    Temperature: afebrile
     Pulse rate : 76 BPM 
     R . R : 17 cps 
     Bp : 130/80 
General examination: 
     Patient consent was taken 
    Patient was examined in well lit room 
    Patient was conscious, coherent, cooperative
 No pallor, icterus, cyanosis , clubbing of finger , lymphadenopathy 
       Systemic examination:  
 Per abdomen: soft no tenderness, bowel sound heard, no organomegaly 
CVS : 
         S1, S2 heard , no added sound heard 
RS: position of trachea central
      Vesicular breath sound heard
CNS : conscious coherent cooperative
 Speech normalwith generalised weakness and numbness over foot since 1 week Telangana PaJR

History of present illness: 
      Patient was apparently asymptomatic 1week ago then she developed generalised weakness which is gradually in onset and numbness
Past history 
     known case of SLE since 10 yrs 
     DM since 6 yrs on medication 
             Glycomed gp
             HCQS 200 mg 
             Whysirol 5 mg 
   Not a known case of HTN ,                   asthma, epilepsy, TB, CAD, CVD 
Family history:
      Irrevalent
 Personal history: 
       Diet : mixed 
      Appetite: normal 
      Bowel and bladder movement          regular
      Sleep : adequate
      No addictions 
Menstrual history: 
    Length of cycle : 15 / 30 
    No of clothes per day : 2 
     Associate with clots but no pain
Vitals : 
    Temperature: afebrile
     Pulse rate : 76 BPM 
     R . R : 17 cps 
     Bp : 130/80 
General examination: 
     Patient consent was taken 
    Patient was examined in well lit room 
    Patient was conscious, coherent,        cooperative
 No pallor, icterus, cyanosis ,   clubbing of finger ,   lymphadenopathy 
       Systemic examination:  
 Per abdomen: soft no tenderness, bowel sound heard, no organomegaly 
CVS : 
         S1, S2 heard , no added sound heard 
RS: position of trachea central
      Vesicular breath sound heard
CNS : conscious coherent cooperative
 Speech normal

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