General medicine long case roll no 6

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

CHIEF COMPLAINT :
A 60 years old female came to opd with chief complains of 5 episodes of vomitings since yesterday
And there is a history of snake bite at right angle region 
Pain and swelling at the bite site and compliments of facial puffiness and has a complaint of decreased urine output since a day
History of present illness:
Patient was apparently asymptomatic a day back later she developed 5 episode of vomiting and facial puffiness and decreased urine output due to snake bite
Pain and swelling is seen at the region of snake bite over right angle region

Past medical history:
Known case of hypertension and the patient is on regular medication
Not a known case of diabetes, asthma, epilepsy, icterus

Personal history :
 She is farmer by occupation,  she wakes up at 6am in the morning and she used do work till 9 am and takes breakfast at 9 am after she went for agriculture field, she does take lunch lat afternoon times and later at 4pm she take lunch , dinner at 7pm after at 8.30 pm she sleeps
Diet: only veg
Apatite: normal
Sleep : adequate 
Bowel movement :normal
Addictions: none

Family history :
 NO RELEVANT FAMILY HISTORY.

Vitals:
GENERAL EXAMINATION 

Vitals: 
Temp: afebrile
Respiratory rate: 18cycles/min
Pulse: 90beats/min
Blood pressure: 130/90mmHg
Sp O2 96%
GRBS: 150mg%

Systemic examination ;
By taking the consent from patient examined in a well ventilated room

Cardiac Examination 
Thrills: No
Cardiac sounds: S1, S2 positive

Inspection:-
Bilaterally symmetrical chest
No visible engorged veins,scars or sinuses on chest

Palpation:-
S1 S2 are heard
No thrills , no murmurs 

Auscultation:-
Cardiac rate - 88 beats per minute 
No cardiac murmurs heard

 ABDOMINAL EXAMINATION
Shape of the abdomen- scaphoid
Flanks: flanks are free
Umbilicus- central and inverted.
no visible sinuses and scars are seen.
No engorged veins 

Palpation:
No local rise of temperature 
No tenderness 
No palpable mass
No organomegaly.

Percussion:
No Fluid thrill
No shifting dullness

Auscultation:
Bowel sounds are heard.
CENTRAL NERVOUS SYSTEM 
Patient is conscious, coherent, cooperatively well oriented to time and place.
Speech: Normal
Sign of Meningitis: No
Respiratory system 
Position of trachea: Central  
 Inspection 
Chest appears Bilaterally symmetrical & elliptical in shape
Respiratory movements normal
No signs of volume loss
No dilated veins, scars, sinuses, visible pulsations. 
No rib crowding ,no accessory muscle usage, no drooping of shoulder.

Palpation :-
All inspectory findings are confirmed
Trachea is in central position 
Chest movements-symmetric

Provisional diagnosis :
Acute kidney disease l, hypertention

Treatment :
Inj pantaprazole 40mg/IV once a day
Inj lasix 20mg/IV/stat
Inj lasix 40mg IV/QID
Inj optineuron 1 ampl in 500 ml ns IV once a day
Inj calcium gluconate 10ml IV/stat
Rab acetazolamide 250mg po/BID



Popular posts from this blog

65 year old female with altered sensorium

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 available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. CASE PRESENTATION: A 65 year old female, came with c/o unresponsiveness since 2 days. Pt was apparently asymptomatic 5 days back ,then she developed pain in right hip and stopped going to work.she also had 1 episode of fever.  She is unable to recognize her family members properly, complaining of some one is going to attack her. She also had an episode of involuntary urination. H/O 90 ml alcohol intake every day since 5 years PAST HISTORY: Not a k/c/o DM/HTN/TB/ASHTMA/EPILEPSY/CAD  H/O Histerectomy 20 years back Personal History : Diet : mixed Appetite : Normal  Sleep : Adequate  Bowel movements : Nor
Read more

GENERAL MEDICINE LONG CASE FINAL EXAMINATION

Image
January 20 2023 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  69 year old male patient with breathlessness and cough with sputum  Cheif complaint  Patient complains of breathlessness since 4days  and cough since 3days.  History of present illness  Patient was apparently asymptomatic 4 days back then he developed breathlessness with gradual onset grade 2-3 associated with chest tightness ,wheeze , seasonal variation, aggrevated on cool air and dust.  Cough with sputum since 3 days ,  mucopurulent, non blood stained, not foul smelling, no season
Read more

A 78/M WITH ABDOMINAL PAIN AND REDUCED URINE OUTPUT

Image
A 78/M WITH ABDOMINAL PAIN AND REDUCED URINE OUTPUT This is an online E log 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. Chief complaints Pain abdomen since 2 days Reduced urine output since 1 day History of presenting Illness Patient was apparently asymptomatic 2 days ago then developed pain in right HYPOCHONDRIUM, insidious oncet, gradually progressive not associated with vomitings and not relieved by bending forward position No history of fever, loose stools, chest pain, palpitations From 1 day patient is having decreased urine output not associated with burning mituration Past history PTCA 10 yrs back  Left-sided hearing loss in 6 years and patient is using hearing aid No
Read more