General medicine

 Hi, I'm Ajitesh Racharla (roll:07), 3rd sem medical student. This is an online e-log book to discuss our patient's health data shared after taking his/her consent . This also reflects my patient centered care and online learning portfolio. CASE SHEET:- Chief complaint; A 29yr old female, resident of Mumbai, customer service executive by occupation came to OPD with chief complaints of Increased sweating 4 days ago Shortness of breath 4 days ago Dizziness 4 days ago Vomitings 2episodes/day before the day of admission  History of present illness; Patient was apparently asymptomatic 5yrs ago. Then she developed ulcers in mouth and painless rash on her face across her nose, hair loss and sensitivity to light on her face.Then she went to a private hospital where she was referred to another doctor where she was diagnosed with SLE. She was given medication for it. Then, 1 month ago, she developed Shortness of breath and went to hospital where she was diagnosed with chronic kidney dise

   Note: This is an online E Log book recorded by Ajitesh Racharla to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent. Chief complaints: No new complaints  HOPI: 61 yr old male patient Railway chief by occupation came for regular health checkup  Patient works in the shift of 8 hours per day with change in duty timings i.e at 6am 2pm 8pm respectively.  The patient was under regular health check up . During one of the health checkups he was diagnosed with DM and HTN in the year 2006. Since then he has been under medication for control of blood sugar levels. Negative History : No History of Headache,Vomiting ,Palpitations and Shortness of Breath, asthma  Past illness: patient was diagnosed with diabetes mellitus and hypertension in 2006  Personal History: Mixed diet Bowel And Bladder-Regular   Sleep Adequate  No Allergies And addictions Family History: Patient’s mother was diabetic  General Examination

 Note: This is an online E Log book recorded to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent. -Ajitesh Racharla 07 -Anirudh Mane 12  A 26 year old patient cab driver by occupation came to the hospital with c/o abdominal pain around the umbilicus  CHIEF COMPLAINTS  The patient has c/o pain in the abdominal region near the umbilicus  And c/o vomitings on the day of addmission  HISTORY OF PRESENT ILLNESS  The patient was apparently asymptomatic 4 months ago. Had sudden onset of pain in the same region as now and was diagnosed with pancreatitis   HISTORY OF PAST ILLNESSES  Patient was treated for pancreatitis with medication  No surgery was done  No h/o DM HTN asthma TB FAMILY HISTORY No h/o similar conditions in his family PERSONAL HISTORY   He is a driver by occupation and had consumed a lot of spicy fast food due to his profession  Appetite has been decreased since 4 months from the onset of pain