GENERAL MEDICINE E-LOG

SUPRIYA GAGIREDDY 42

Hi,I am supriya 8th 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 portfolia

CHIEF COMPLAINTS

 A 48 year old male came with chief complaints of           
       - Abdominal distention since 2 months
       - Bilateral pedal edema since 2 months
       -Decreased appetite since 2 months
       - Decreased urine output since 1 month
 

HISTORY OF PRESENTING ILLNESS

Patient was apparently alright 2 months back then he developed abdominal distention which is insidious in onset gradually progressive associated with decreased appetite since then. 
Bilateral pedal edema extending upto knee since 2 months , pitting type increased on walking and relieved with rest
Decreased urinary output since 1 month 
No h/o fever, cough, breathlessness    
 
Daily routine: He get up at 5 in the morning do his daily activities and go to work at 6 in the morning.He reaches his work place in 15mins which is 5km away from his home. He goes by riding cycle. He has his breakfast 9 in the morning. Do his work and have lunch at 1.Return to home at 8 in the nyt and drinks alcohol 180ml.In the day time he also smokes beedi 1pack per day. He eats rice and curry daily 2times.






PAST HISTORY :

No h/o DM HTN TB asthma epilepsy CVA CAD.


PERSONAL HISTORY :
Mixed diet
Normal apetite
Sleep adequate
Bowel and bladder -regular
Consumes 180ml  alcohol occasionally and stopped 1 year back.
Smokes beedi 1 pack per day and stopped 3 months back

GENERAL PHYSICAL EXAMINATION:

Patient is conscious ,coherent and cooperative and well oriented to time, place and person.

moderately built and nourished.

Pallor-absent

Icterus -absent

Cyanosis-absent

Clubbing-absent

Generalised Lymphadenopathy-absent

Edema-bilateral pedal edema present




VITALS:

Temperature - 98.2F

PR :- 95bpm

RR : 22cpm

BP :- 110/70mm Hg

SPO2 :- 98%@RA

GRBS :- 110mg/dl.


SYSTEMIC EXAMINATION 

Per abdomen - 

Abdominal girth- 93-->91cm



Inspection- 

Abdomen is distended , flanks are full, skin is stretched  , no visible peristalsis , equal symmetrical movements in all quadrant’s with respiration 

Palpation - 

No local rise of temperature,  no tenderness

All inspectory findings are confirmed by palpation, no rebound tenderness, gaurding and rigidity.

No tenderness , No organomegaly 

Fluid thrill present 

Abdominal girth- 93-->91cm

Percussion:

Shifting dullness present 

Auscultation:

Bowel sounds heard 

CVS : S1 and S2 heart sounds heard

CNS: NO focal neurological deficits 

RR: BAE Present, normal vesicular breath sounds heard,no adventitious sounds

INVESTIGATIONS 














Ascitic tap - 

Appearance - clear , yellow coloured 

SAAG - 1.65 g/dl

Serum albumin - 2.0 g/dl

Asctic albumin - 0.35 g/dl

Ascitic fluid sugar - 104mg/dl

Ascitic fluid protein - 0.7 g/dl

Ascitic fluid amylase - 17 IU /L

LDH : 143 IU/L 

Cell count- 50 cells 

Lymphocytes nil

Neutrophils 100%.

PROVISIONAL DIAGNOSIS

Chronic liver failure with Ascites? 

TREATMENT :

Tab LASIX 40 mg PO BD

Syp. Lactulose 10 ml  PO HS

Strict Alcohol abstinence 

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