Wednesday 20 January 2016

38 year old man headache with hypertrntion since 3 year

38 year old man complain headache with hypertention since 3 yrs. shaking feeling on head. pain. n neck pain. urin passes drop by drop.pt smoking n taking alcohal.

28 yr old woman IUFD with pain in left lower limb after delivery since 5 month

28 yr old woman pain in left lower limb during walking since 5 month. pt unable to walk. swelling on leg during walking. 5 continue IUFD.

65 year old man multiple polycystic kidney since 1 yr

pt complaining fullness of abd [when empty abd] with vertigo n constipation. pt also complaning piles last 1 yr. pt start dilysis since 4 month.

45 years old woman with left sided whole body pains and both knee pains since 15 years and diabetes since 3 years

This is a HIPAA de-identified open-online-patient-record, posted on autumn 2015 after collecting informed patient consent (form downloadable here ) by LNMCH research assistant and patient-information-communication-executive Dr Jyoti


Patient history:



a 45 yr old woman complaining of difficulty in walking n stair climbing due to B\L knee pain.

pt also complaining pain in left side of whole body n heaviness of lt side of head.

On  examination :- during palpation muscular pain at left scapular muscle difficulty in long standing n radiating pain numbness n tingling sensation from back

Investigations:





Hospital duty doctor notes:

45 yrs/FM
K/C/O-DM2 with Lumber Radiculopathy
Present History- pain in Rt.upper and lower limb FBS-141Mg/dl PPBS- 393mg/dl
Adv-
Physiotherapy; Moist heat+exercise Pt is stable
Rx
Tab Daonil5mg1..0..1/2
Tab metfarmin 500mg BD
Tab tryptomer 25 mg HS
Tab PCM 500 mg QID
Tab Ultracet QID






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