GENERAL MEDICINE E BLOG

 General medicine

                                             Sreeja K 

                                         Roll no:168

  

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

Case scenario:

70 years old male daily wage labourer by occupation came to the casuality with 

C/O SOB with wheeze since 2 years .

Chief complaints:

PEDAL EDEMA 

FACIAL PUFFINESS since 6 months on and off .

Shortness of breath with wheeze since 2 years.

History of present illness:

Patient was apparantly asymptomatic 2 years ago then patient developed on and off sob associated with wheezing associated with dry cough since 2 years , and used to go to local RMP and take medications .

Since last 6 months patient complaints of pedal edema gradually progressive with facial puffiness used some medication and on taking that medications pedal edema got subsided.

Since last 2 months sob aggrevated ( grade 2 to grade 3 ) and associated with orthopnea , PND , episodes of sweating , shivering , giddiness on and off .

No h/o chest pain , palpitaions , fever , decreased urine output .

No loss of appetite .

Non diabetic, non hypertensive 

PERSONAL HISTORY:

Marital status - married 

Occupation - daily wage labourer 

Appetite - Normal 

Diet - Mixed 

Bowel and bladder movements - regular

Addictions - 

Chronic alcoholic since 50 years daily 90 ml.

Chronic smoker since 60 daily 4-5 beedis per day.

No significant family history .

GENERAL EXAMINATION :

Patient is conscious , coherant, cooperative well oriented to time,place,person.

PHYSICAL EXAMINATION:

No pallor , icterus , cyanosis , lymphadenopathy, edema .

VITALS:

BP : 240/120 MM HG

PR : 88/ MIN

RR : 18/ MIN

SPO2: 98% on RA

GRBS : 99 MG %

SYSTEMIC EXAMINATION:

CVS : S1, S2 +

RS : BAE + , NVBS , WHEEZE IN SSA , ISA , INFRA SCAPULAR AREA , SMA , IMA . 

P/A : soft , nontender 

CNS : NO FND 

INVESTIGATIONS: 

PROVISONAL DIAGNOSIS :

AE COPD WITH? CORPULMONALE

? HEART FAILURE 

DENOVO HTN

CKD

Treatment:

1)NEB.DVOLIN 

            BUDECORT

2)INJ.LASIX 80mg stat given

    INJ.LASIX 40mg IV BD

3)TAB.NICARDIA 20mg P.O stat given

4)TAB.CINOD 10 mg P.O BD

5)TAB NODOSIS 500mg PO BD

6)TAB.ECOSPIRIN AV (75/20) PO BD

7)TAB.ACEBROPHYLLINE 100mg PO BD

8)TAB.WYSOLONE 10mg PO BD

9)TAB.PAN 40mg PO BD.