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2nd internal assessment

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A 20 YEAR OLD FEMALE WITH HEADACHE, VOMITING AND NECK PAIN

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This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient 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 comments in comment box are most welcomed  I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  A 20 year old female presented with chief complaints of  headache, neck pain since 4 days and  vomitings since  3 days HOPI:- patient was apparently asymptomatic 4 days back the she developed hea...

internal assessment 1

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A 55yr old female complains of fever,decreased appetite since 1 month, Breathlessness since 1 week,vomitings and loose stools since 3 days.

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CHIEF COMPLAINTS: Pt complains of fever,decreased appetite since 1 month, Breathlessness since 1 week,vomitings and loose stools since 3 days .  HOPI: Patient was apparently asymptomatic 3 months back. Then she had multiple swellings in front of the left ear, for which she developed fever which was lowgrade, intermittent, no evening rise of temp, ass with decreased appetite since 1 month. She then had vomitings which was non bilious and non projectile, containing food particles. She had history of loose stools since 3 days, which is 4-5 episodes per day, watery in consistency.  Past history: K/c/o  Hypertension since 7 years.  7 yrs back she had c/o giddiness for which she went to hospital and was found to have HTN.  Personal history: Diet- mixed Appetite-decreased Bowel and Bladder movements- regular. Addictions- Allergies- none General examination : Patient is conscious, coherent and cooperative. Well oriented to time, place and person. Moderately built and mo...