GENERAL MEDICINE E-LOG

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32 CH SRILEKHA,  5th sem

This elog depicts the patient -centered approach to learning . This is an online E log book recorded to discuss and comprehend our patients de-identified health data shared , after taking his /her /guardians signed informed consent . This elog also reflects patients centered learning portfolio.

CASE

A 47year old female patient ,tailor by occupation, resident of nalgonda , came to OPD with chief complaints of 

1. Difficulty in swallowing since 3 months

2.Vomitings since 3 months

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 10years back ,then she developed joint pains associated with morning stiffness lasting for < 10mins. Then 2years back she developed decrease in vision.  Then 3 months back she developed difficulty in swallowing and pain during chewing, and vomiting after taking food. She also had dental caries. 

Patient is tailor by occupation, but she stopped working 10years ago, due to joint pains and decreased vision. 

HISTORY OF PAST ILLNESS

Not a known case DM, HTN, asthma , TB. 

PERSONAL HISTORY

Marital status : Married

Occupation : Tailor

Diet : Mixed

Appetite: Loss of appetite

Bowels : Regular

Micturition : Normal

She has no known allergies

No addictions

TREATMENT HISTORY

She had used medication for joint pains 10years back for 2months and stopped it as it got relieved. But again recently she started developing joint pains .

FAMILY HISTORY

No Significant Family History

GENERAL EXAMINATION

Patient is conscious, coherent , cooperative and examined in a well lit room. 

Moderately built and nourished.

VITALS 

Pulse Rate: 84/min

Blood pressure: 130/80mmHg

Respiratory rate: 18/ min

Temperature : 98.6°F

Spo2 : 98%

PHYSICAL EXAMINATION

Pallor : present 

Icterus : absent

Cyanosis : absent

Clubbing of fingers and toes : absent 

Lymphadenopathy : absent

Edema : absent

Malnutrition : absent

Dehydration : absent

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

S1 and S2 are heard 

No thrills

No murmurs

RESPIRATORY SYSTEM

Dyspnea : absent

No wheezing

Trachea : central

Vesicular breath sounds : Normal

PER ABDOMEN

Shape : Obese

Tenderness : absent

No palpable mass

Hernial orifices : Normal

No free fluid

No bruits

Bowel sounds : present

 CENTRAL NERVOUS SYSTEM

Conscious

Speech : Normal

No signs of meningeal irritation

Cranial nerves :  intact

Motor system : Normal

Sensory system : Normal

Reflexes : Normal

INVESTIGATIONS

ULTRASOUND 


COLOR DOPPLER 2D-ECHO


UGI ENDOSCOPY


ECG


RETICULOCYTE COUNT 


HEMOGRAM 


ERYTHROCYTE SEDIMENTATION RATE (ESR)


COMPLETE URINE EXAMINATION (CUE)


BLOOD GROUPING AND RH TYPE


BLOOD SUGAR RANDOM


BLOOD UREA


LIVER FUNCTION TEST (LFT)


SERUM CREATININE


SERUM ELECTROLYTES


SERUM IRON


PROVISIONAL DIAGNOSIS

Dysphagia with decreased evaluation .

K/c/o ? Mixed connective tissue disorder /? Sjogrens syndrome.

TREATMENT

INJ.OPTINEURON 1amp in 100ml NS IV/OD

INJ.PANTOP 40mg IV/BD

INJ.ZOFER 4mg IV/SOS

TAB.WYSOLONE 10mg PO/TID

TAB. OROFER-XT PO/OD

SYP.ARYSTROZYME 25ml PO/TID 20mins before food.

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