General Medicine E-log by Shishira Reddy

Tuesday, September 13, 2022

70year old man with chief complaints of pedal edema since 15 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 70 year old man toddy tree climber, came to casualty with the chief complaints of

1) B/L pedal edema since 20

2) facial puffiness since 20days

History of presenting illness:

Patient was apparently asymptomatic 3yrs back when he complained of generalized weakness on & off for which their sons convinced him to stop climbing trees.

He to used wake up at 6 am , used to do his routine activity followed by breakfast and tea by 9am. He used to sit in the corridor and play with the kids , talk to neighbour. He used to have his lunch at 11am , sleeps for 1-2 hrs. He used to have dinner by 7pm .

20 days back when pt woke up from bed , he suddenly noticed pedal edema, pitting type and facial puffiness.

No c/o chest pain , palpitations, SOB.

Burning micturition since yesterday.

Nausea and 1 episode of vomiting which was non bilious and a/w food particles

Cough intermittent since 7 days

Past history:

H/o bleeding PR since 1 year

N/k/c/o DM , HTN, EPILEPSY, ASTHMA, TB.

PERSONAL HISTORY:

Sleep adequate,

Appetite normal

Diet mixed

Bowel - irregular,

Bladder regular

Addiction: regular alcoholic , 90ml whisky

Smoking -20 beedis per day

Family history

Not significant

General examination

Patient is concious

. Pallor - present

No Icterus, clubbing, cyanosis, lymphadenopathy

Edema of feet grade 3

Temp- 98.3°F

BP:140/70mmHg

PR:76bpm

RR:21cpm

CVS: S1 S2 +

RS:BAE +

CNS: NAD

P/A: Soft , non tender

Provisional diagnosis:

Severe Anemia under evaluation with bleeding PR 2° ? Fissure? Malignancy

Investigations:

13/09/22

LFT

Serum creatinine

14/09/22

ecg

15/09/22

Hemogram

Treatment:

1)INJ .IRON SUCROSE 200 mg in 100 ml NS IV / OD

2)INJ LASIX 40 mg IV/ OD

3)INJ ZOFER 4 mg IV / TID

4)SYP CREMAFFIN 30 ml PO/ OD / HS

5) TWO EGG WHITES PER DAY

15-09-22

O/E

Pt is c/ c/c

Temp- Afebrile to touch

BP- 110/70mm hg

PR- 82 bpm

SpO2- 98% with RA

GRBS- 112mg/dl

CVS- s1, s2 +

CNS- NAD

LUNGS- BAE+, NVBS

1)INJ .IRON SUCROSE 200 mg in 100 ml NS IV / OD

2)INJ LASIX 40 mg IV/ OD

3)INJ ZOFER 4 mg IV / sos

4)SYP CREMAFFIN 30 ml PO/ OD / HS

5) TWO EGG WHITES PER DAY

6)MONITOR VITALS AND INFORM SOS only

16-09-22

S: dizziness, tinnitus

Pt is c/c/c

Temp. 99°F

BP: 110/70

PR:84

SPO2 98%

CVS- S1, S2 +

RS-BAE+

CNS-NAD

GRBS- 92mg/dl

A: Severe Anemia under evaluation with bleeding PR 2° ? Fissure? Malignancy

1) INJ. IRON SUCROSE 200ml NS/IV/OD

2) INJ. LASIX 40mg/IV/OD

3)INJ. ZOFER 4mg/ IV/SOS

4) SYP. CREMAFFIN 30ml/PO/OD/HS

5)TWO EGG WHITES /DAY

6) MONITOR VITALS &INFORM SOS

7) TAB. VERTIN 16mg PO/BD

17-09-22

Hemogram

18-09-22

Hemogram

AMC bed 4,

70 year old male.

S: bleeding PR

Pt is c/c/c

Temp. 98°F

BP: 110/70mmHg

PR:78bpm

SPO2 98%

CVS- S1, S2 +

RS-BAE+, NVBS

CNS-NAD

GRBS- 108mg/dl

A: Severe Anemia under evaluation with bleeding PR 2° ? Fissure? Malignancy

1) INJ. IRON SUCROSE 200mg in 100 ml NS/IV/OD

2)INJ. ZOFER 4mg/ IV/SOS

3) SYP. CREMAFFIN 30ml/PO/OD/HS

4) TAB. PROMETHAZINE 10mg/PO/TID

5) OINTMENT ANOBLISS

5)TWO EGG WHITES /DAY

6) MONITOR VITALS &INFORM SOS

Sunday, August 21, 2022

44 yr old man with chief complaints of pedal edema since and decreased urine output

A Shishira Reddy

1701006005

ICU Bed 5, 44yr old man

Chief complaints:

A 44year man came with chief complaints of

-B/L pitting type of pedal edema since 10 days , ----decreased urine output since 5 days

- pain abdomen since 4 days

-vomiting 1 day back

History of presenting illness:

He was asymptomatic 1 one and 1/2 yrs back , then he had swelling in face and lower limbs and visited doctor , and was on medication . He stopped medication after 10 days.

After few days he had difficulty in breathing (SOB grade 2) and decreased urine output

He was admitted to hospital and was on dialysis for 2 days .

Since then he was on dialysis twice every week.

Patient was apparently asymptomatic 10 days back and gradually developed B/L pitting type of pedal edema & decreased urine output.

Pain in the epigastric region since 4 days , pricking type of pain, non radiating, aggravated after food and relieved on its own after some time .

History of vomiting of 6-7 EPISODES which was non bilious , consisted of food particles and was relieved on medication .

Past history:

K/C/O HTN since 4 years but didn't use any medication

N/K/C /O DM ,TB , EPILEPSY, ASTHMA.

Personal history:

Diet: mixed

Appetite: normal

Sleep: adequate

Bowel n bladder: irregular , decreased urine output progressed to anuria.

Addiction: alcohol consumption qty: 180ml 3-4 times a week at night , since 15years

And stopped since 1and 1/2 year.

No History of smoking

Family history: no significant history

General examination

Pt is concious and coherent and cooperative well oriented to time place and person,

On examination

Pallor present( mild) , no icterus/ clubbing/ cyanosis / lymphadenopathy /edema (apparently)

Temp: 98°F

BP : 140/100mmHg

RR: 28/min

PR : 80/min

SPO2: 99% @ RA

CVS: S1 S2 +

RS : BAE +

CNS : NAD

P/A : tenderness and pain in the epigastric region

Provisional diagnosis: ?acute gastritis

CKD on MHD, HTN +

Investigations

21/08/22 RFT

21/08/22 LFT

21/08/22 ABG

20/08/22 ECG

20/08/22 HEMOGRAM

20/08/22 ABG

19/08/22 SERUM ELECTROLYTES

19/08/22 TROPONIN

Plan of treatment:

1.Fluid and salt restriction

2. INJ. ZOFER 4 mg IV/ TID

3. INJ. TRAMADOL 1 AMP in 100 ml NS IV / SOS

4. TAB. NICARDIA 10 mg PO/TID

5. TAB. ARKAMIN 0.1mg PO/BD

6. TAB. MET- XL 25 mg PO/OD

7. TAB. SHELCAL 500mg PO/ OD

8. Cap. BIO-D3 PO/OD/WEEKLY ONCE

9. INJ. ERYTHROPOIETIN 4000 IU S/L WEEKLY TWICE

10. BP MONITORING 2nd hrly

11. GRBS 2nd hrly.

Tuesday, June 7, 2022

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

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