19 year old male with swelling& pain in the right foot

September 16, 2022

Hello, I am Harika Madala, a 3rd sem medical student.
This is an online e-log book to discuss our patient's health data shared after taking her/his/guardian's consent. This also reflects patient centred care and online learning portfolio.

Chief complaints 

A 19 year old male, farmer, resident of West Bengal presented to the OPD with chief complaints of 
Swelling& pain in the right foot while walking 
Pain while standing after sitting for a long time

History of Present illness 

Patient was apparently asymptomatic 8 months ago then he started getting pain in the right ankle which subsided on medication. He continued to have pain on& off for 5 months. Later he went to an RMP doctor where he prescribed medication but pain& swelling graduated increased. He then visited a doctor and MRI was done which showed infection for which surgery was done.

History of Past illness 

No DM
No HTN
TB- Yes since 1 1/2 month
No Asthma
No Epilepsy
No CAD

Personal history

Normal appetite 
Adequate sleep
Mixed diet
Regular bladder& bowel movements

Family history 

Not significant 

Drug history 

Not significant 

Allergies 

No known allergies 

Addictions 

No addictions 

Surgical history 

Surger was performed on the right foot 

General examination 

The patient is conscious, coherent, cooperative and well oriented 
No pallor 
No icterus 
No cyanosis 
No clubbing of fingers 
No lymphadenopathy 
No pedal edema 
Vital signs 

Vital signs

Temperature: 98.1 F
Pulse rate: 100 beats/min
Respiration rate: 17 cycles/min
Blood Pressure: 110/90 mm Hg 
SPO2: 99%

Systemic examination 

CVS
S1 S2 heard
No murmurs

Respiratory system 

Dyspnoea- No
Wheezing- No

ECG


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