INTERNAL ASSESSMENT -2

B. VAISHNAVI
ROLL NO. -22
9 TH SEM

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  B.VAISHNAVI 3RD SEMESTER ROLL NO. 22 This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan. A 45 year old female farmer by occupation presented with chief complaints of abdominal pain and vomiting since 4 days, headache since 1 day.  HISTORY OF PRESENTING ILLNESS: Patient was apparently asymptomatic 5 days back. On Wednesday around 7:30 pm, pt alleged to be bitten by snake on right foot went to the local hospital, she is fine for 1 day. Had  swelling of right lower limb, went to the local hospital ( ointment  given)swelling subsided.  Complained of vomiting(2-3 episodes), bilious ( food as content) since 4 days. Pt complained  of abdominal pain si
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general medicine case presentation

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40 yr old male patient who is daily wage labourer by occupation came to OPD with Chief complaint of pain abdomen since 5 days associated with fever since 2 days  HOPI Patient was apparently asymptomatic 5 days ago then he developed pain which is insidious in onset and gradually progressive which is  diffuse , squeezing  type and radiating to back . Pain is relieved on medication . No C/O of vomitings , loose stools , burning micturition ,cough,cold , chest pain , SOB  Past history:- N/K/C/O TB , hypertension, diabetes, Asthma, epilepsy , CAD, thyroid disorders . Personal hisrory:- Diet - mixed  Appetite- normal Bowel and bladder -regular Sleep - adequate Addictions - regular alcohol  intake of 250 ml per day  since 20 yrs . No food allergies and drug allergies General examination:- Pallor - yes  Edema -absent  Clubbing - absent  Lymphadenopathy - absent  Icterus - absent  Cyanosis absent  Vitals:- Temperature - 100.1F BP-85/60 Spo2- 98% RR-20pm PR- 100/min Systemic examination:- Per ab
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