A 72 year old male

  Hello,I am D.Sai Deeptha  3rd sem medical student. this is an online elog book to discuss our patients health data after taking his consent.  A 46 year old patient, driver by occupation, came to the hospital with chief complaints of pain in abdomen and lower back.  HISTORY OF PRESENT ILLNESS  The patient was apparently asymptomatic 8 moths back.He has been suffering from gastritis from past 20 years and feels better after taking the medicines. He is unable to sleep properly since last 8 months due to pain the lower back. PAST HISTORY   No DIabetes Mellitus,  No Hypertension  No TB,  No Epilepsy ,  No Asthma.  PERSONAL HISTORY :  Chronic cigarette smoker Drinks alcohol occasionally  Diet- mixed Appetite- normal  Has constipation  Sleep-inadequate  PHYSICAL EXAMINATION : Patient is conscious and coherent No pallor No icterus No clubbing  No pedal oedema  No lymphadenopathy  Malnourished/thin  No cyanosis        

Hi , I am D Sai Deeptha I, 3rd semester student.  This is an online elog book to discuss our patients health data after taking her consent.  This also reflects my patient centered online learning portfolio. A 72 year old daily wage worker, resident of Nalgonda was admitted into the hospital  with cheif complaints of jaundice since 10 days and fever since 5 days. HISTORY OF PRESENT ILLNESSES:  Patient came with the chief complaint of jaundice but later he was diagnosed with haemorrhoids once again. He had intermittent fever since few days. Has pain in left hypochondrium. Has pedal Edema since 15days..   PAST ILLNESS: Heamorrhoids: has since 3-5 years got treatment few years back.  Chills, rigors, fever- since few days  No cold , no cough SOB-  present ( in supine position) Vomitings :Nil  Constipation - present  Weight loss- present   PAST HISTORY: HTN- was diagnosed 6 years back  Diabetes- Present  Family history-  2 sons suffering from polio , died 20 years ago  Appetite- reduced sinc