27 year old female with chief complaints of generalised weakness and headache

Hi, I am Gaddam shreya of 3rd semester .This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio.

The patient’s consent was taken verbally prior to history taking and examination of her condition.

A 27 year old female student came to OPD with the cheif complaints of generalised weakness since 1 month, headache since 1 month.

HISTORY OF PRESENT ILLNESS -
Patient was apparently asymptomatic 1 month ago.
Then she developed generalised weakness.
History of weight loss, decreased food intake, increased menstrual bleeding and cycles are regular.
Headache since 1 month which is insidious in onset, gradually progressive, pain is localised to frontal region especially on the left side, non radiating, no aggravating factors, headache relieved on medication.
Recurrence of headache is observed.

PAST HISTORY
Not a known case of diabetes, hypertension,asthma,TB,CAD,CVD, Thyroid disorders.

PERSONAL HISTORY 
DIET: Mixed
APPETITE : Normal
BOWEL AND BLADDER: Regular
SLEEP: Inadequate 
ALLERGIC HISTORY: No known allergies
NO ADDICTIONS

FAMILY HISTORY
No relevant family history

GENERAL EXAMINATION
patient is conscious, coherent and Co-operative
patient is moderately build and moderately nourished.
Pallor present 
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
No Oedema of feet

VITAL SIGNS-
TEMPERATURE:98.6 degree F
PULSE RATE:86bpm
RESPIRATORY RATE: 16cpm
BLOOD PRESSURE:130/90 mm Hg
SpO2:98%

SYSTEMIC EXAMINATION
CVS:
S1 S2 Heard,
no murmurs 

RESPIRATORY SYSTEM:
No scars are seen on inspection
Shape of the chest:
Tracheal position:Centre
Bilateral Chest Movement 
Tracheal position is confirmed by palpitation
Dyspnea present 
Wheeze absent 
Breath sounds are Vesicular

ABDOMEN-
Abdomen is scaphoid
No tenderness
No palpable mass
Non palpable liver and spleen
Bowel sounds are not heard

CENTRAL NERVOUS SYSTEM 
Conscious 
Speech- normal
Signs of meningeal irritation - 
no neck stiffness
no kerming's sign
Cranial system - intact 
Motor system - intact 
Sensory system - intact 
 Cerebeilar signs
    Finger nose- in coordination
    Knee heel - in coordination

INVESTIGATIONS-
CBP - hemoglobin:-8.7gm/dl

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