A 17 year old male patient came to general medicine OPD with the cheif complaints of dragging pain in the neck.


Hi, I am M. Sohith Mahadeva Reddy 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 his/her condition.

A 17 year old patient studying BscMLT came to general medicine OPD with the chief complaints of dragging pain in the neck


HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 3 days ago
He developed dragging pain in the neck since 3 days, when he was in hostel
He had given blood sample on 18th December in Miryalaguda which revealed low hemoglobin 
He was then admitted in KIMS on 19th Dec where he developed back pain


HISTORY OF PAST ILLNESS: 

He had similar complaints at the age of 8 for which he had undergone blood transfusion along with medication

No known DM,HTN,TB,epilepsy,thyroid disorders, asthma, 


FAMILY HISTORY: 

Father is hypertensive 
No family member had similar complaints

PERSONAL HISTORY:

Normal appetite
Mixed diet
Regular bowel habits
Normal micturition
No addictions
No allergies 

GENERAL EXAMINATION:
Patient was conscious, coherent and cooperative
Moderately built
Moderately nourished
Patient was icteric
No pallor, lymphadenopathy, clubbing, cyanosis, pedal edema

Vitals:
Temperature: 99.7 °F
Pulse rate : 98 beats/min
Respiratory rate:19 breaths/min
Blood pressure: 120/80 mm Hg
SpO2: 98%
GRBS: 152 mg/dl

LABORATORY INVESTIGATIONS: 


FEVER CHART:


ECG:
































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