Usually we use to write fever chart in *SOAP* format- top to bottom. S- subjectivecomplaints- Next day , mention the same, whether it was subsided or not . O- In objective , I used to include those parameters only, which I want to monitor daily... ( because I don't want to make it clumpsy). Like - abdominal girth in Ascites . Daily weight measurement in Heart failure. A- in Assement , I used to mention the investigations,which I used to monitor daily. Like - TLC in Sepsis . But my friends and other interns used to mention every investigation though it was normal, which I was not interested. P- plan . .. please mention the drugs along with interventions that you are giving to patient... On next day , mention if any new drugs were added .. Or mention if any drug was stopped.
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome." Chief compliants : 1) Slowness of movements since 1 year . 2) Involuntary movements of the Left upper limb. 3) Slowness in speech since 1 year. History of present illness : 60 year old female,who is a mother of 3 children ( 1 son and 2 daughters ), labour by occupation ( goes to agriculture field ) was apparently asymptomatic 1 year back, then developed Slowness of movements which was insidious onset, gradually progressive not associated with any wea...
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome." Chief compliants: Absent Menstrual cycle 6 months back. History of present illness : Patient was apparently asymptomatic 6 months back, then she developed absent Menstrual cycles not associated with any pain abdomen and vomtings and then she went to the gynecology OPD and on routine evaluation , the ultrasound abdomen showed altered renal echotexture and Urine analysis showed Proteinuria and she was referred to general medicine department for further ...
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