General medicine elog

General medicine elog 

Hi , I am G.M Sai Bhuvanesh,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 55 year old female patient who is resident of choutuppal, nalgonda district and  labourer by profession came to OPD with chief complaints of fatigue, Shortness of breath 

History of present illness

Patient was apparently asymptomatic 2 days back but she developed fever associated with chills and rigor and no urination and defecation and has shortness of breath and fatigue.and she was confirmed of diabetes

Past history

Hypertensive for 5 years

Patient had experienced same type of symptoms of fatigue, shortness of breath and swelling of leg 3-4 years back and took treatment and later symptoms again appeared 1 1/2 years back and was diagnosed as kidney failure and received treatment for one week and later she came to hospital one month back and has undergone dialysis for 4 times in one week. And  has one episode of fits during dialysis

Personal history 

Appetite- reduced

Diet - mixed 

Bowel and bladder movements- decreased urine output and loose stools

Sleep- reduced 

No addictions

Family history 

Nil

General  Examination 

Patient was unconscious

Thin built , moderately nourished

Vital signs

Temperature - 

Pulse rate- 

Respiratory rate-

Bp-

SpO2 -

RBS- 















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