GENERAL MEDICINE E-log-1

A 80 years old female came with shortness of breath and dry cough for the past 3 days.

Hi,I am Tharun 3rd sem medical student.This is an online e block to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio         

Cheif complaints : shortness of breath and dry cough for the past 3 days.

HOPI: 80 years old female came to causality with complaint of shortness of breath and dry cough for the past 3 days, patient was apparently alright 3 days back then she developed shiverness of breath which was insidious in onset and gradually increased and progressive and increased on exertion.

PAST HISTORY:

20 years back she had complaints of giddiness and headache for which she went to hospital and eventually diagnosised with hypertension for which she was prescribed with atenolol+amlodipine

6 years back she had complaints of polyuria she went to hospital and diagnosied with Diabetes Mellitus type-ll and she was persisted metformin 500mg

3 years back she had complaints of abdomen pain in iliac fossa for which she was admitted in hospital and diagnosised to have appendicitis and has undergone appendectomy

2 years back she had similar complaints of shortness of breath mild B/L pedal edema for which she was diagnosed with B/L preural effusion, left lower rib collapse and pulmonary edema and her 2D echo finding showed dilated right and left atria,concortric LVH , moderate PAH and diastole dysfunction.

1 year back also she had complaints of shortness of breath which was diagnosed as pleural effusion and was given conservative prescription

DRUG HISTORY:                                                        atenolol+Amlodipine for hypertension.          Metformin 500mg for diabetics mellitus.        

GENERAL EXAMINATION:

Pallor - present

Cyanosis - no

Icterus - no 

Temp : 98.6F

Pulse rate : 42/min.      

SPO2 at room air 96% at RA litres of O2. 

GRBS - 127mg%


SYSTEMIC EXAMINATION :

CARDIO VASCULAR SYSTEM:.                               Cardiac sounds  S1 , S2 

RESPIRATORY SYSTEM:

Dyspnoea: yes 

Breath sounds - vesicular

ABDOMEN:

No tenderness

No palpable mass

Spleen - not palpable

Bowel sounds - yes

CNS:

Conscious 

Speech - normal 

PROVISIONAL DIAGNOSIS :

Heart failure

Cardiogenic pulmonary edema 

INVESTIGATIONS:

ECG 

















Comments

Post a Comment

Popular posts from this blog

78 year old male came to OPD with chief complaints of bilateral pedal edema since 2 months

 A 78 year old male came to OPD with chief complaints of bilateral pedal edema since 2 months HOPI Patient was apparently asymptomatic 2 months back then he developed bilateral pedal edema (pitting type) which was sudden in onset and gradually progression. PAST HISTORY - Known case of hypertension since 1 year and using medication for it (clindipine) - Similar complaint of pedal edema an year ago and it was relieved by medication  No DM No TB No Syphilis No CVA No CAD - H/O surgery for renal calculi 5 years back  Family history. No significant family history Drug history Patient is on clindipine since 1 year Personal history Diet - Mixed Appetite - abnormal Bowel movements - irregular Bladder movement - regular Sleep - adequate No allergic history Addictions Consumes alcohol and tambaku PHYSICAL EXAMINATION A. General Examination Conscious  coherent and cooperative Moderately built No pallor No icterus No cyanosis No clubbing of fingers No lymphadenopathy Pedal edema VITALS. Temperatur
Read more

General medicine e log 2

Image
  Hi,I am Tharun 3rd sem medical student.This is an online e block to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio  A 45 years old male came with SOB, B/L pedal edema  CHEIF COMPLAINT:c/o SOB, B/L pedal edema since one month  HOPI: patient was apparently asymptotic 1 month back then he developed SOB and pedal edema  HISTORY OF PAST ILLNESS:   K/c/o Hypertension (3 years) TREATMENT HISTORY : No diabetes , CAD, asthama, TB  PERSONAL HISTORY : Apetite normal  Micturation normal  Bowels - regular  FAMILY HISTORY :  Diabetics - NO  Hypertension - NO  Heart disease - NO  Stroke - NO  PHYSICAL EXAMINATION  GENERAL :  No pallor  No icterus  No cyanosis  No clubbing of fingers  No lymphadenopathy  No Oedema of feet  No malnutrition  No dehydration  Pulse rate : 86/min  Respiration rate : 16/min  BP : 140/80 mm/hg  SPO2 at room air 98%  SYSTEMIC EXAMINATION  CARDIO VASCULAR SYSTEM  No thrills  S1 S2 cardiac sounds  Car
Read more

A 30 yr old female patient came to opd with chief complaints chest pain and pain at back of chest

 A 30 yr old female patient came to opd with chief complaints chest pain and pain at back of chest  HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic 6 months back,then she developed chest pain which was episodic for every 15 days,pain was aggregating while breathing and doing work,and reliving during medication, pain was radiating towards the back of chest  PAST HISTORY: She had undergone with hysterectomy 6 years back  N|K|C|O  Hypertension, Diabetes, epilepsy, asthma, TB FAMILY HISTORY: Not relevant Drug history: Nil PERSONAL HISTORY: Diet : Mixed Appetite : normal Sleep: inadequate due to chest pain Addictions : Nil Bowel/ bladder: regular bowel movements Allergies: nil GENERAL EXAMINATION: Conscious coherent cooperative  Moderately built Moderately nourished  No pallor   No Icterus   No Cyanosis  No clubbing of finger  No lymphadenopathy Pedal edema with pain present while sitting for long time about 30 min,then it was relive  by walking ,it was present from past  6
Read more