Hi, I am Yeddula Vishnu Priya, 3rd semester medical student. This is our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. This elog also reflects my patient centered online learning portfolio.
CHIEF COMPLAINTS
A 28 year old male, resident of Nalgonda presented to opd with a chief complaint of pain in the epigastrium and abdominal tightness
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 6 days back, then he developed fever at night - 103°F, with chills and rigors but not associated with nausea/ vomiting/ loose stools. burning micturition.
Patient went to local practitioner who gave Dolo 650 mg (QID) and suggested to take plenty of oral fluids then the fever subsided.
Next day evening patient again developed fever with chills but subsided after taking symptomatic medications
Patient now complaints pain in abdomen at epigastrium not subsiding (even with antacids)
Patient also complaints tingling sensation of all 4 limbs since evening not associated with numbness/ postural hypotension/ giddiness/ pain/ weakness
No hematemesis or black tary stools seen
HISTORY OF PAST ILLNESS
No HTN/diabetes
He had a right limb fracture 7 years ago and a nail placement was done
PERSONAL HISTORY
Patient is farmer by occupation
Unmarried
Bowel movement is regular
Micturition abnormal
Non alcoholic
FAMILY HISTORY
No significant family history
PHYSICAL EXAMINATION
A. GENERAL EXAMINATION
Well built
Well nourished
No pallor
No icterus
No cyanosis
No pedal oedema
No clubbing of fingers
No lymphadenopathy
Mild dehydration
B. VITALS
Temperature - 99°F
Pulse -
Respiratory rate -
BP -
INVESTIGATIONS
Hemogram - 01/09/2022
Serum creatinine - 01/09/2022
CUE - 01/09/2022
Hemogram - 05/09/2022
TPR CHART
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