🍁Greetings to one and all going through my E log!!
🩺This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment.
I am Nomika Alli (Roll no 179) of 8th Sem MBBS.
A 27yr old male, lorry driver by occupation, R/O Narketpally came to OPD with c/o inability to walk since 3 days.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 3 days ago then he found himself unable to walk suddenly. It was sudden in onset, gradually progressive. Patient was not able to comb his hair, unbutton his shirt.
No H/O Trauma, LOC, Seizures, head injury. Patient is not able to walk without support since 3 days. No H/O urinary incontinence present.
No H/O bowel and bladder incontinence
His daily routine is waking up at 6: 00 am, drinks tea at 7:00 am, breakfast as rice and curry at 8:00 am and leaves for work. He used to have his lunch as rice and curry at 1: 00 pm and return to home by 5:00pm. He usually haves his dinner as rice and curry at 8:00pm and goes to bed by 10:00 pm.
HISTORY OF PAST ILLNESS:
N/K/C/O DM, HTN, TB, Asthma, CAD, CVD
H/O Chyluria 14 months back
NO SURGICAL HISTORY
FAMILY HISTORY:
N/K/C/O DM, HTN, TB, Asthma, Epilepsy, CAD, CVD
PERSONAL HISTORY:
Diet: Vegetarian
Appetite: Normal
Sleep: adequate
Bowel and bladder movements: Regular
Addictions: No
Allergies: no known
GENERAL EXAMINATION:
Patient is conscious, coherent, cooperative to time, place and person.
Ht: 170 cm Wt: 78kg
No signs of pallor,
no icterus,
no clubbing,
no cyanosis,
no koilonychia,
no lymphadenopathy,
no edema
vitals: temp: afebrile
BP: 110/80 mmHg
HR: 78 bpm
RR: 18cpm
SpO2: 99%
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MANAGEMENT:
1)TAB. VITCOFOL PO/OD
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