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