General medicine elog 2

 June 14,2022

Hi,We are 3rd sem medical students,Ananya Nayak and A Naga Pravallika. this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.

A 55 yr old man,farmer by occupation,resident of nalgonda,was admitted in the hospital with complaints of Shortness of breath(grade 3),pedal edema,low urine output ,nausea and loss of appetite. 


HISTORY OF PRESENT ILLNESS-

The  patient was apparently alright 3 days back.He was brought to the casuality and he had shortness of breath (grade 2-3) not associated with any orthopnea.There is pedal edema which is of pitting type.

No fever 

No cough

Reduced appetite 

Patient had shortness of breath 3 days back which aggrevated while doing work.He was also having shortness of breath while answering our questions .

Before patient had no urination for 2 days so he visited another hospital in nalgonda. Urination problem subsided but the doctor suggested that he had low BP and low pulse rate.And then he was admitted in our hospital.

On 13 june 2022 ,at 8-30pm he had acute decompensated heart failure secondary to CAD.He had ischemic hepatitis and pre renal acute kidney injury.

Yesterday night he had burning micturition.

He has diabetes mellitus ,hypotension,tachycardia.


PAST HISTORY -

Case of pulmonary Kochs(used ATT for 9 months)

Case of diabetes mellitus since 1 year.

No similar complaints in the past.


PERSONAL HISTORY-

Diet-mixed

Reduced appetite

Regular bowels 

Burning micturition, low urine output

Sleep cycle is normal

Alcoholic since 20 years

No allergies

Hypotension 

Diabetes mellitus 


FAMILY HISTORY-

No such significant family history found.

No asthma

No Diabetes 


NEGATIVE HISTORY-

no headache,asthma, epilepsy,htn


GENERAL EXAMINATION-

Poorly nourished and built

Conscious,coherent, cooperative 

No pallor 

No icterus 

No cyanosis 

No clubbing of fingers

Pitting pedal edema

VITALS-

BP-90/60 mm of Hg

Pulse -86beats /min

SpO2-97%

Heart Rate-98 beats/min

Temperature-98.1


SYSTEMIC EXAMINATION-

RS-BAE+

CVS-S1,S2 +

PA-Soft,non tender

CNS-NAD

GIT-No swellings,no tenderness 

SPEECH-NORMAL

SENSORY SYSTEM-Responding to pain

DOMINANCE-Right handed





































Comments

Post a Comment

Popular posts from this blog

52M with PYREXIA ,SOB,BODY PAINS

Image
 30 October 2023 Hi ,I am Ananya Nayak, 6th sem medical student. This is an online elog book to discuss our patient’s health data after taking his consent.This also reflects my patient centered online learning portfolio. 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 based evidence based inputs. A 52 yr old male patient farmer by occupation came to the OPD with chief complaints of fever since 10 days . HISTORY OF PRESENT ILLNESS- Patient was apparently asymptomatic 10 days back.Then he developed fever which was high grade,sudden in onset, intermittent in nature aggrevated during night and on exertion. It is associated with body pains(aggrevated on exertion),chills and rigor.It is not associated with cough,cold,vomitings,headache. Patient has complaints of Shortness of breath on exertion since 10 days.No PND,Orthopnea. PAST HI
Read more

55yr old with aspiration pneumonia and Parkinsonism

Image
 June 20,2022 Hi, I am Ananya Nayak, 3rd sem medical student. this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio. A 55 year old male patient,farmer by occupation resident of Nalgonda came to the casuality with the complaints of Shortness of breath and fever 6 days ago.  HISTORY OF PRESENT ILLNESS- The patient was apparently asymptomatic 10 days back.Then he developed shortness of breath and he was unable to eat and drink anything properly. He was diagnosed with Aspiration Pneumonia and Pulmonary Kochs. Onset-insidious Gradually progressive Fever-on and off since 10 days,not associated with chills and rigor ,relieved on medication.  Cough-since 6 months A significant weight loss is seen and loss of appetite. No case of chest pain,chest tightness,dizziness. Ryles tube is used . At first, he was admitted in pulmonology department then he was transferred to General Medicine department as
Read more

General medicine elog

Image
1 July ,2022  33 yr old female with Moderate MR and severe PAH Hi, I am Ananya Nayak, 3rd sem medical student. this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio. A 33yr old female patient came who is a housewife and a resident of Bengal came to the OPD with chief complaints of Shortness of breath and bilateral  knee joint pain.She was admitted in the SS Ward on  HISTORY OF PRESENT ILLNESS-   The patient was apparently asymptomatic 2yrs back. Then she developed shortness of breath which gradually aggrevated on lifting heavy objects and exertion. 1 year back she developed bilateral knee joint pain which gradually aggrevated on exertion and subsided at rest. Onset-insidious  The pain was progressive for which she went to a hospital in Bengal and was treated conservatively.It subsided after taking medications but after the medications were over the symptoms reappeared.  2 months ago,pati
Read more