General medicine E-log

-

32 CH SRILEKHA, 8th 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.


55 year old male came to opd with chief complaints of fever and yellowish discoloration of eyes and tongue( jaundice) since 15days


HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 15 days ago when he developed fever which was insidious in onset, low grade, gradually progressive in nature, associated with chills and rigors.

No hlo loose stools, vomitings

Pedal edema was noted by patient 2 days ago, pitting type

No h/o decreased urine output or burning micturation.

H/o cough since 1 day, non productive, dry cough.

No hlo chest pain, palpitations and sob

H/o yellowish discoloration of eyes and tongue since 15 days

No h/o bleeding per rectum, haematuria .






PAST HISTORY


K/c/o Diabetis mellitus II since 6 years, on unknown medication

N/k/c/o HTN, BA ,CVA , CAD , TB, Epilepsy

H/O Leprosy ? Hypopigmented patches ,7 months ago.



Medication one month ago?

No surgical history

H/o Blood transfusion , 5 days back. No reactions. Indications?


PERSONAL HISTORY

Married

Mixed diet

Decreased Appetite

Regular Bowel and bladder

No allergies 

Alcoholic since 20 years, stopped one year ago.


FAMILY HISTORY

Not significant 


GENERAL EXAMINATION:


Patient is conscious, coherent and co-operative,well oriented to time,place and person.

Moderately build and well nourished.

Examination was done in a well lit room.

Pedal edema + ( grade 2)

Icterus +

No pallor, cyanosis,clubbing,lymphadenopathy

Vitals

PR- 96 bpm

BP- 130/80 mm Hg

RR- 16 cpm

Temp -100 F

GRBS - 144 mg/dl




SYSTEMIC EXAMINATION



ABDOMEN 

Inspection

Shape - Slightly distention.

Umbilicus - Everted

Equal movements in all the quadrants with respiration.

No visible pulsation,peristalsis, dilated veins and localized swellings.

No scars , sinuses 



Palpation

Soft, non tender


Auscultation

Bowel sounds heard



RESPIRATORY SYSTEM 

Bilateral air entry present

B/L Crepts in ISA,IAA, Right Infra Mammary

Vocal resonance decreased



CVS EXAMINATION 

S1 S2 heard( Slightly muffled), no murmurs




CNS EXAMINATION 

No focal neurological deficits

Higher mental functions normal

Cranial nerves normal

Sensory examination normal sensations

Motor examination normal

Reflexes normal

INVESTIGATIONS

31/10/23


















1 Nov 

2 NOV






3 NOV




PROVISIONAL DIAGNOSIS

? Drug induced hepatitis

K/c/o Leprosy

K/c/o DM II

Dapsone syndrome?

With anaemia 


TREATMENT

INJ.PIPTAZ 2.25 iv/ TID

INJ. Lactulose 10 mg PO/BD

INJ.Actrapid s/c according to GRBS

T. Dolo 650 mg PO/TID



Comments

Post a Comment

Popular posts from this blog

General medicine E-log

-
Image
32 CH SRILEKHA, 8th 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. 58 yr old with stroke November 28, 2023 58 year old male construction worker by occupational came with chief complaints of Burning sensation at right upper half of the body since 2years History of present illness Patient was apparently asymptomatic 2years than one night he suddenly  complained  of loss of vision in both eyes and he developed weakness of right upper limb and lower limb and deviation of mouth to left side which is sudden in onset preceeded by 30-40 episodes of vomiting non-bilious , non-blood tinged, projectile which was associated with involuntary movements of both upper limbs and lower limbs , associated with frothing , tongue bite , outward fixation of l
Read more

General medicine E-log

-
Image
32 CH SRILEKHA, 8th 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. CHEIF COMPLAINTS:  28 years male autodriver by occupation admitted in hospital with c/o fever since 5 days HOPI: patient was apparently asymptomatic 5 days back then he developed intermittent low grade fever a/w generalised body pains, headache, and giddiness. Lots of appetite, not a/w chills and rigor no diurnal variation  No history of malena, hematuria No complaints of chest, pain, cough, cold No complaints of burning micturition No complaints of loose stools, nausea, vomiting PAST HISTORY : Not a known case of hypertension, diabetes, thyroid, CAD CVA TB PERSONAL HISTORY: Appetite: normal Diet: mixed Addictions: no Sleep: adequate bowel regular  General examination: Pt
Read more

General medicine E-log

-
Image
32 CH SRILEKHA, 9th 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. 48 yr male with ascites, pedal edema since 2 months CHIEF COMPLAINTS  A 48 year old male came with chief complaints of                   - Abdominal distention since 2 months       - Bilateral pedal edema since 2 months        -Decreased appetite since 2 months        - Decreased urine output since 1 month   HISTORY OF PRESENTING ILLNESS Patient was apparently asymptomatic 2 months back then he developed abdominal distention which was insidious in onset gradually progressive associated with decreased appetite since then.  Bilateral pedal edema extending upto knee since 2 months , pitting type increased on walking and relieved with rest Decreased urinary output since 1 mon
Read more