GENERAL MEDICINE CASE DISCUSSION

SUPRIYA GAGIREDDY 42

Hi,I am supriya 5th sem medical student.This is an online elog book to discuss our patients de-identified health data shared after taking his/her/guardians signed informed consent.Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.This E-log book reflects my patient centered online learning portfolio. 




Date of admission : 27/07/2022

CASE

A 46 year old male patient, farmer by occupation, resident of nalgonda came with chief complaints of 

1. Shortness of breath since 6years

2.Cough since 4years which is on and off

3. Pedal oedema and facial puffiness since 3years.

4. Abdominal distension since 3years. 

5. Hard stools since 10 days. 

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 6years ago. Then he developed shortness of breath which was initially grade 1 and gradually progressed to grade 2 . Cough since 4 years (on and off) which is productive with yellow colored sputum. Then he developed abdominal distension , pedal oedema and facial puffiness 3years back. For which he visited a hospital in miryalaguda 3years back and it relieved on medication for a year and again reappeared 2 years back. Hard stools since 10 days. 

DAILY ROUTINE:He wakes up at 5AM in the morning and works in the animal shed like cleaning the shed, and does his breakfast at 10AM and goes to herd his sheeps and comes back home at 6PM,skips his lunch and have his dinner at 9PM in the night and goes to sleep at 10PM.

HISTORY OF PAST ILLNESS

Not a known case of HTN, DM, TB, epilepsy, CAD.

PERSONAL HISTORY

Marital status : Married 

Occupation : Shepherd and farmer

Diet : mixed

Appetite : Normal

Sleep : not adequate

Bowel movements : irregular (hard stools since 10 days)

Micturition : normal

Addictions 

Alcohol : Regular since 30years (stopped drinking from April 2022) 

Tobacco : smoking (1 pack of beedi everyday since 30 years) 

He has no known Allergies. 

TREATMENT HISTORY

Cataract was done 1year ago in left eye.

FAMILY HISTORY 

No significant family history. 

DRUG HISTORY

Not Significant

GENERAL EXAMINATION

Patient is conscious , coherent , cooperative and examined in a well lit room. 

VITALS

Pulse Rate: 88/min

Blood pressure:130/70mmHg

Respiratory rate: 

Temperature : 98.6°F

Spo2 : 98%

GRBS : 205mg%

PHYSICAL EXAMINATION 

Pallor : absent 


Icterus : absent

Cyanosis : absent

Clubbing of fingers and toes : absent 

Lymphadenopathy : absent

 Edema : Bilateral pitting type of Pedal oedema present



Malnutrition : absent

Dehydration : absent

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

S1 and S2 are heard 

No thrills

No murmurs

RESPIRATORY SYSTEM

Dyspnea : present

Wheezing : present

Trachea : central

Vesicular breath sounds : Normal

PER ABDOMEN
INSPECTION

Distended shaped abdomen

Hernial orifices : Umbilical hernia present(umbilicus is everted)

No visible pulsations

Caput medusae : present

PALPATION

NO Tenderness in any quadrants of abdomen, liver and spleen.

Liver and spleen - not palpable

No palpable mass

PERCUSSION

Shifting dullness - present

Free fluid -?present

Fluid thrill : absent

AUSCULTATION


Bowel sounds : present

No bruits





CNS

Conscious

Speech : Normal

No signs of meningeal irritation

Cranial nerves : intact

Motor system : Normal

Sensory system : Normal

Reflexes : Normal

INVESTIGATIONS

ULTRASOUND 

ECG
HEMOGRAM







PROVISIONAL DIAGNOSIS

Moderate ascites

Heart failure

TREATMENT

On 27/7/2022

INJ. LASIX 40mg IV/BD

Neb. Duolin 8th hourly

Neb. Budecort 8th hourly

On 28/7/2022

Inj. Lasix 40mg IV/BD

Neb. Duolin 8th hourly

Neb. Budecort 12th hourly

Tab. Azithromycin 500mg PO/OD

Tab. Montac LC /PO/OD

Tab. Metformin 500mg PO/OD

On 29/7/2022

Inj. Lasix 40mg IV/BD

Neb: Duolin 8th hourly

Neb: Budecort 12th hourly 

Tab. Azithromycin 500mg PO/OD

Tab. Montac LC PO/OD

Tab. Metformin 500mg PO/OD

Comments

Post a Comment

Popular posts from this blog

BIMONTHLY BLENDED ASSESSMENT - JUNE 2021

NAME:G.SUPRIYA REDDY ROLL NO:42  Question 1: Competency tested for Peer to peer review and assessment : Please go through one particular answer of ten students in this link:  https://generalmedicinedepartment.blogspot.com/2021/06/bimonthly-formative-and-summative_19.html?m=1 and share your peer review of each answer with your quantitative marking input as well as qualitative insights into what was good or bad about the answer.  1 PULMONOGY   REVIEW: https://akash688.blogspot.com/2021/05/online-blended-bimonthly-assessmentmay.html   CASE:https://soumyanadella128eloggm.blogspot.com/2021/05/55-year-old-female-with-shortness-of.html   This is a case of Acute exacerbation of COPD associated with right heart failure and bronchiectasis.She is presented with shortness of breathe,genaralised weakness,facial puffiness,drowsiness and decreased urine output.She is a known case of Diabetes Mellitus for the past 8 years.She is a known case of Hypertension.The treatment for all the symptoms has gi
Read more

General medicine case discussion

Image
 G. Supriya reddy 42 67 year old male, sarpanch by occupation resident of nalgonda came with chief complaints of  cough since 1month and  breathlessness since 1month. HISTORY OF PRESENT ILLNESS Patient was apparently normal 1month back. Later he developed shortness of breath since 1 month. Increased on lying down, exertion, decreased on sitting position, taking rest. History of wheeze, cough since 1month with expectoration, mucoid, non foul smelling, No diurnal or postural variation, h/o decreased urine output since 1week.H/o pedal edema since 1week . Loss of appetite, no loss of weight. H/o chest pain, abdominal distension, Tendernrss, pain and fever.  HISTORY OF PAST ILLNESS H/o similar complaints  in past since 2years. Not a known case of Hypertension, diabetes mellitus, CAD.  No history of TB or covid 19 PERSONAL HISTORY APPETITE-Normal Mixed diet BOWELS-Regular MICTURITION-Decreased urine output since 1week ADDICTIONS-Occasional alcoholic, beedi 40/day FAMILY HISTORY No family his
Read more

GENERAL MEDICINE E-LOG

Image
  42  SUPRIYA GAGIREDDY 3rd sem Under the guidance of deepika mam INTRODUCTION : CASE HISTORY AND CLINICAL FINDINGS : 19 year female came to casuality with chief complaints of  2-3 episodes of vomitings ,which is non projectile .Non bilious associated with food particles.5 days back high grade fever.Intermittent ,relieved on medication. Fever subsided 1 day back. HISTORY OF PRESENT ILLNESS : No H/o cold,cough,SOB,Headache Pain abdomen,loose stools Hematuria,Malena,Rash No other complaints PAST ILLNESS : No H/O DM,HTN,ASTHMA,EPILEPSY,CAD,TB PERSONAL HISTORY : No significant personal history FAMILY HISTORY : No significant history GENERAL EXAMINATION VITALS : TEMPERATURE:AFEBRILE PR:96BPM RR:18CPM BP:100/70MMHG SPO2:98%AT RA GRBS:150MG/DL SYSTEMIC EXAMINATION : CVS :S1,S2 HEARD RESPIRATORY SYSTEM :BAE+ NVBS HEARD PER ABDOMEN :SOFT' NON TENDER CNS :NFND INVESTIGATIONS : ECG-NO SIGNIFICANT CHANGES HEMOGRAM:1/8/2021 HB12.77GM TLC4300 CELLS/CU MM PLATELETS:54000CELLS /CU MM RBC:NORMOCYTI
Read more