General Medicine E-log by Shishira Reddy: June 2022

Tuesday, June 7, 2022

71 year old male with chief complaints of breathlessness and cough since 20 days

This is 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 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 also reflects my patient centered online learning portfolio and your valuable inputs on 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 diagnosis and treatment plan.

A Shishira Reddy

1701006005

Chief complaints-

A 71 year old male ,Mason by occupation came to the general medicine OPD on 1st June,2022 with chief complaints of

. breathlessness since 20 days

.cough since 20 days

.fever since 4 days

Daily routine-

He is Mason by occupation since 25 years.Daily he used to wake up at 7 am and goes to work by 9 am and return home at 5 pm.He doesn't wear mask while working.He sleeps at 10pm

History of present illness-

Patient was apparently asymptomatic 2 months back,then he developped breathlessness which is insidious in onset, gradually progressive(MMRC grade-1)

2 months back, he visited near by government hospital where he was given medication. Symptoms were relieved temporarily.

20 days back breathlessness was progresses to MMRC grade-2 to 3

.Associated with wheeze

.Aggrevated on cold exposure,exertion

.Relieved on rest

.No orthopnea and PND

20 days back,he developped cough with expectoration

.Mucoid in consistency

.Non foul smelling

.Non blood stained

.Aggrevated at night

4 days back,he developed fever,which is continuous and low grade

.Evening rise of temperature is present

.Relieved on medication

.Not associated with chills and rigors

General examination-

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

He is thin built and moderately nourished.

.Temperature-99°F

.Pulse rate-83 beats per minute

.Respiratory rate-20 cycles per minute

.BP-120/80 mm of hg

.SpO2-95%at room air

.Pallor- absent

.Icterus-absent

.cyanosis- absent

.Clubbing- absent

.Lymphadenopathy- absent

.Edema- absent

Systemic examination-

Respiratory system-

Inspection-

.Shape of chest-bilaterally symmetrical,elliptical

.Trachea- shift to right side

.Chest movements-decreased on right side

.No kyphosis and scoliosis

.No crowding of ribs

.No scars,sinuses,visible pulsations,engorged veins

.No usage of accessory muscles

Palpation-

.All inspectors findings are confirmed

.No local rise of temperature and tenderness

.Trachea-shift to right side

.Chest movements- decreased on right side

.Chest expansion-decreased on right side

Vocal fremitus on the right upper lobe

Percussion-

.Dull note heard on right upper part of chest

Auscultation-

.Normal vesicular breathsounds heard

.Decreased breath sounds on right upper lobe

.crepitations present on right mid axillary area

CVS-

.S1 and S2 heard

.No murmurs

Per abdominal examination-

.Shape of the abdomen- scaphoid

.Soft,non tender,no organomegaly

.Bowel sounds- heard

Provisional diagnosis-

Right lung upperlobe consolidation

Investigation

CBP

CUE

Culture

LFT

HRCt

Treatment

1).Inj.augmentin-1.2 gm IV TID

2).Inj.pantop-40 mg OD

3).Tab.paracetomol-650 mg BD

4).syp.Ascoril-2 Tbsp

5).Nebulization with .budecort-BD

.Duolin-TID

.Mucomol-TID

6).oxygen inhalation with Nasal prongs@2.4 lit/ min

7).Tab.Azee-500 mg OD

Monday, June 6, 2022

A 40 year old female with chief complaint of abdominal distension and facial puffiness since 1 year

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 available 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-centered online learning portfolio and your valuable inputs on the comment box .

Name : A Shishira Reddy
I would like to thank Dr. Keerthi for providing with the case details.

40/F Came with complaints of

Abdominal Distension since 1 year

Facial puffiness since 1 year

Itching all over the body since 1 year and developed multiple plaques on abdomen and Lower limbs

Sob since 5 days

pedal edema since 5 days pitting type

H/O PRESENT ILLNESS

Patient was apparently asymptomatic 1 year back then she developed abdominal distension, facial puffiness,itching all over the body and 5 days ago she developed pedal edema and SOB grade 3.

she had an episode of vomiting two days back which contained food particles. It was relieved on medication.

PAST HISTORY

she developed B/L Knee pain - since 3years, onset - insidious, gradually progressing, type- pricking, more at the night, aggravated on walking, relieved on sitting n sleeping, no radiation and is under medication( demisone 0.5 mg and acelogic SR)

She developed abdominal distension and facial puffiness one year back.

She also developed itching and skin lesions and was diagnosed as tinea and was given medications.

Not a K/C/O DM/HTN/ asthma / Ischemic heart disease / epilepsy / TB

FAMILY HISTORY

NO SIGNIFICANT FAMILY HISTORY

PERSONAL HISTORY:

OCCUPATION Daily wage worker , stopped going to work since 3 months

DIET MIXED

APPETITE decreased

SLEEP NORMAL

BOWEL AND BLADDER HABITS : decreased urine output

ADDICTIONS: NO

GENERAL EXAMINATION

Patient is concious coherent and coperative, well oriented to time palce and person

VITALS

BP 110/80

PR 90bpm

TEMP 98.5degrees F

SPO2 98 @ RA

GRBS 106

No Pallor , ICTERUS , CYANOSIS, CLUBBING , LYMPHADENOPATHY ,

SYSTEMIC EXAMINATION

CVS-

Inspection :

Apex beat 5th intercostal space

Palpation

Apical impulse - medial to mid clavicular line at 5th ics

Auscultation

Mitral area

Aortic area

Pulmonary area

S1 S2+ heard , no murmurs, or any added sounds

P/A-

Inspection:

Abdomen is distended