Patient name-- ACACIA463NILOTICA(02)
This is a HIPAA de-identified open-online-patient-record with initial information in duty-doctors notes as well as patient's voice, posted here spring 2016 after collecting informed patient consent (form downloadable here) by our patient-information-communication-executive ,managed by Dr.Madhavi.
C/O=> Burning on abdomen& chest since 2year.
Mouth ulceration ,constipation, acidity since 2year
LBA since 2 Months
Cyncope some time since 15 days..
PATIENT History in patient voice:--
CLINICAL IMAGES:-
A
This is a HIPAA de-identified open-online-patient-record with initial information in duty-doctors notes as well as patient's voice, posted here spring 2016 after collecting informed patient consent (form downloadable here) by our patient-information-communication-executive ,managed by Dr.Madhavi.
C/O=> Burning on abdomen& chest since 2year.
Mouth ulceration ,constipation, acidity since 2year
LBA since 2 Months
Cyncope some time since 15 days..
PATIENT History in patient voice:--
CLINICAL IMAGES:-
A
MEDICAL HISTORY:-- not significant
SURGICAL HISTORY:-- cataract operation (Rt eye), 6Month ago.
OBS.HISTORY:-- 9 P< 5M,4F, 1 Die 10 hours after birth
All child ND at home
LCB- 30 yr/ M
SURGICAL HISTORY:-- cataract operation (Rt eye), 6Month ago.
OBS.HISTORY:-- 9 P< 5M,4F, 1 Die 10 hours after birth
All child ND at home
LCB- 30 yr/ M
MENSTRUAL HISTORY:-- menopause since 16Year
FAMILY HISTORY:-- not significant
PERSONAL HISTORY:-- tobacco & supari chewing since 2Year.
NUTRITIONAL HISTORY:-- nonvagaterian.
PSYCHO-SOCIAL=>
-patient behavior- good
- family adjustments- good
- earning source-majduri
OBJECTIVE EXAMINATION:--
• General= skin- normal colour
Tongue- ulceration
Posture- normal
Gait- normal & head slightly forwarded.
• Palpation= abdomen- softy & normal
Lower back area- no muscular spasm.
•Auscultation= chest - normal sound
• Musculo-skelatal examination=
Lumber ROM- all movement are normal Range of motion
Muscle tone- normal
Muscle power-- U.L& L.L all muscle power grade 5
INVESTIGATION=>
- CBC
URIN< R,M
- USG abdomen.
ANALYSIS= Gastric ulceration.??
PLANING=
FAMILY HISTORY:-- not significant
PERSONAL HISTORY:-- tobacco & supari chewing since 2Year.
NUTRITIONAL HISTORY:-- nonvagaterian.
PSYCHO-SOCIAL=>
-patient behavior- good
- family adjustments- good
- earning source-majduri
OBJECTIVE EXAMINATION:--
• General= skin- normal colour
Tongue- ulceration
Posture- normal
Gait- normal & head slightly forwarded.
• Palpation= abdomen- softy & normal
Lower back area- no muscular spasm.
•Auscultation= chest - normal sound
• Musculo-skelatal examination=
Lumber ROM- all movement are normal Range of motion
Muscle tone- normal
Muscle power-- U.L& L.L all muscle power grade 5
INVESTIGATION=>
- CBC
URIN< R,M
- USG abdomen.
ANALYSIS= Gastric ulceration.??
PLANING=
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