GENERAL MEDICINE: A 46 year old Male

This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 

I have been given this case to solve in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

A 46 year old male who is resident of Bhongir and by occupation a Barber came to OPD on 11th of January at 4:10 pm.

CHIEF COMPLAINTS:
Fever on and off episodes:12 days

Loss of appetite:12 days

Pedal edema:7 days

Shortness of breath :7 days

Jaundice:7 days

HISTORY OF PRESENT ILLNESS:
-Patient was apparently asymptomatic 12 days back then he complained of fever which is low grade, intermittent, on and off episodes get relieved on medication. 

-Patient complained of B/L pedal edema present below the knees, pitting type, present since 7days which get aggravated on standing for long periods and slightly reduced on taking rest. 

-Shortness of breath present since 7 days which is grade 2(developing shortness of breath while walking to washroom). 

-Patient also complained of loss of appetite :12 days

-Patient also complained of abdominal tightness, bloating of abdomen. 

-No History of chest pain, chest tightness, palpitations. 

-No History of abdominal pain, vomitings, constipation, loose stools. 

-No History of burning micturition, decresaed urine output. 

-No bowel and bladder irregularities. 

-No Head ache, Giddiness, Confusion. 

HISTORY OF PAST ILLNESS:

-K/C/O: Hypertension: 3 years on unknown medication.
-Not K/C/O: DM,TB, CAD, Asthama, Epilepsy.

FAMILY HISTORY:not significant

PERSONAL HISTORY:

-Appetite:Normal(Decreased since 12 days) 

-Diet:Mixed

-Bowel and Bladder habits:Regular

-Addiction: patient consumes alcohol since 25 years (90ml)

-Tobacco chewing since 5 years. 

GENERAL EXAMINATION:
-Patient is conscious, coherent and cooperative.
-Well oriented to time, place and person.
Moderately built and well nourished.
-Temp:afebrile
-Pallor: yes
-Icterus: yes
-Cyanosis: no
-Clubbing of fingers: no
-Lymphadenopathy: no
-Pedal oedema: yes

VITALS:
-BP: 110/70mmHg 
-PR: 100bpm
-RR: 16 cpm
-SpO2: 98%

SYSTEMIC EXAMINATION:

CNS examination:

-Patient is conscious, coherent and cooperative.
-Speech is normal.
-NAD(no abnormality detected)

CVS examination:

-S1, S2 are heard.
-No murmurs.


Respiratory system examination:

-Bilateral air entry present.Normal vesicular breath sounds heard.Position of trachea central.


Abdomen:
Inspection:
Shape of Abdomen:Distended
Umbilicus:Everted
No Dilated veins, visible peristalsis, engorged veins, scars.
Palpation:
Liver : palpable 
Spleen: not palpable
Percussion:
Resonant note heard
Auscultation:
Bowel sounds heard. 

Provisional diagnosis:
- Chronic liver disease


CLINICAL IMAGES:

INVESTIGATION:
-Hemogram:
-Blood grouping & RH type:
-Clotting time:
-Serum Creatinine:
-Blood Sugar:

-ECG:
-TREATMENT:
-Inj Monocef 1gm IV/BD
-Inj Neomol 1gm IV
-Syrup Lactulose 30ml PO/BD
-Inj Lasix 20mg IV/BD
-Inj Thiamine 100mg 
-Tab Rifagut 550mg
-Tab Udiliv 300mg
-Metadoxine
-FINAL DIAGNOSIS:
.Decompensated Chronic Liver Disease
. Moderate anemia


Popular posts from this blog

TRAUMATIC RAW LEG

Image
This is an online E-blog to discuss our patient identified health data shared after taking the consent. Here we discuss our patient problems through series of inputs available. A 26 year old male with post traumatic raw leg over the anterior aspect of upper half of the Right Leg. CHIEF COMPLAINTS   -Patient came to OP with A/H/O fall from bike on 23/02/22 at Hyd. -Patient sustained injuries to Rt lower limb. -No injuries marked. -Patient gave history of small abrasion wound to the RT leg. -Following which he developed swelling to the RT leg -Local Doctor did debritment following which he developed Blisters in the present wound.   HISTORY OF PRESENT ILLNESS - A/W pain -No C/O any long bone tenderness HISTORY OF PAST ILLNESS .No DM .No Hypertension .No BP .No Surgical history   PERSONAL HISTORY . Married . Occupation-Bussinesmen . Appetite- normal .Bowel -Regular .Non- Vegetarian .Micturition- Normal   FAMILY HISTORY . No DM .No Hypertension .No CAD IN
Read more

General Medicine

Image
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 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-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan. A 45 year old female patient came to the hospital with the chief complaints of vomiting since 3 days  HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic 3 days back, then she h
Read more

A 61 year old female

Image
This is an online e-log platform to discuss case scenario of a patient with their guardians permission.  I have been given this case to solve in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including histoty, clinical findings, investigations and come up with a diagnosis and treatment plan. CASE: A 61 year old female who is resident of narketpally, came to OPD on 21st november at 12am with Chief complaints of:  - stiffness of muscles of hands and neck  - slurred speech - deviation of mouth towards right. History of present illness: Patient was apparently asymptomatic 10yrs back and then she developed faintness, numbness and tingling sensation, burning sensation of hands and foot espcially during night and was diagnosed with Diabetes Mellitus for which she is on medication. 8months back she developed neck pain, headache, leg pain, body pains and was diagnosed with Hypertension for which she is on
Read more