84 Moovika Reddy Siddenki

Thursday, 30 November 2023

35YR MALE WITH C/O ABDOMINAL SWELLING

This is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed 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 .

A 35 year old male house contractor by occupation from Miryalaguda came to general medicine OPD with chief complaints of swelling in feet and abdomen since 2days

Tingling sensation,cough since 1 week , difficulty in intake of food.

History of presenting illness:

Patient was apparently asymptomatic 2days back then he developed edema in lower limbs which is insidious in onset gradual in progression and pitting type? and then he developed swelling in abdomen insidious onest gradual progression

h/o nausea ,tiredness and tingling sensation after eating food

No h/o vomiting, pain abdomen

H/o cough non productive type , because of cough he was having discomfort in food and water intake while swallowing.

Past history:

2 months back patient had distended abdomen feet swelling went to local hospital there he had tingling sensation and numbness hiccups also then they kept him in ICU for 3 days ,later he was referred to Kims

He was adviced for weekly checkup

N/K/C/O : Diabetesmellitus, Asthma , epilepsy, thyroid disorders, Hypertension

Personal history:

Patient now wakes up at 4 am , then

Have breakfast dosa , because of tingling sensation after food intake , he preferred not to eat anything

In evening he drinks jawa

Appetite is reduced

consumed mixed diet

Sleep disturbance since 2 years wakes up during sleep sometimes sleeps for 4 to 5 hrs and watches tv if he don't get sleep

Bowel and bladder movement are regular

Addiction for alcohol intake since 10 years intitially once a week and then it became 4 to 5 times a week of 1 quarter every time

(stopped from 2 months )

Now:

Wednesday, 19 July 2023

General medicine internal assignment

45 year-old male with generalised weakness

This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

A 45 year old male from Miryalaguda, farmer by occupation came to the OPD with complaints of •generalised weakness

•mild shortness of breath since 5 months.

HOPI-

•Patient was apparently asymptomatic 5 months back, then he developed fatigue and weakness on continued exertion.

• Two episodes of blood loss while passing stools, 6 months back.

•h/o shortness of breath since 5 months, not associated with palpitations, orthopnea, pnd.

Past History-

Not a known case of DM, HTN, asthma, TB, CVD, epilepsy

Personal History-

Diet: Mixed (more vegetables than meat, and fish)

Appetite: Adequate

Sleep: disturbed sleep due to leg pain

Bowel and bladder: normal

Addictions: Smoking since 25 years (10/day)

Allergies: None

Family History-

Not relevant

Treatment History-

Not significant

->GENERAL EXAMINATION:

Patient is examined in a well lit room after taking informed consent.

Patient is conscious, coherent and cooperative, well oriented to time and place.

Pallor: present

Icterus: absent

Clubbing: absent

Koilonychia: absent

Lymphadenopathy: absent

Pedal edema: absent

Vitals

PR: 96bpm

BP: 110/60

->SYSTEMIC EXAMMINATION:

CVS : S1,S2 +, No added sounds.

R/S : BAE+, Clear.

P/A : Soft, Non tender, No organomegaly.

CNS: NFND

Investigations:

Provisional Diagnosis:

Microcytic hypochromic anemia secondary to two episodes of blood loss.

Treatment:

Blood transfusion on day of admission

10 PRBC on 18/7/23

Pantop 40mg

OROFER XT

NEUROBION FORTE

INJ VITCOFOL

Thursday, 1 September 2022

65 year old male with shortness of breath

E-LOG GENERAL MEDICINE

Hi, I'm Moovika , a fifth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them

Case scenario

Chief complaints-

A 65 year old male, farmer by occupation came to OPD with the chief complaintsof -

SOB since 2 months

Loin pain since 2 months

History of presenting illness-

Patient was asymptomatic 2 months ago and then he gradually developed SOB grade 2 which is aggravated on exertion and relieved on rest and medication

He also developed loin pain which was also relieved on medication and rest

History of past illness-

K/c/o DM since 1 year

K/c/o Hypertension since 3 years

Personal History-

Married

Vegetarian

Bowel movements regular

Micturition normal

No known allergies

FAMILY HISTORY

Also has a history of DM and Hypertension

GENERAL EXAMINATION

- No - pallor /icterus / cyanosis / lymphadenopathy / clubbing

- BP - 120/60 mmg

- PR - 70 /min

-RR- 22 /min

- SPo2 -98% at RT

- Temp - 97 degree F

SYSTEMIC EXAMINATION

— CVS

- Thrills : No

- Cardiac sounds - S1 , S2 heard

- Cardiac murmurs : No

— RS

- Dyspnea : yes

- Wheeze : yes

- Position of Trachea : central

- Breath sounds : vesicular

— ABDOMEN

- Shape of abdomen : scaphoid

- tenderness not present , no palpable mass

- Hernial orrifices : Normal

- No fluids

- Liver and Spleen are not palpable

- Bowel sounds : yes

— CNS

- patient is conscious

- speech is normal

- No signs of meningeal irritation

- Higher motor functions intact

Investigations -

Ultrasound report-

Treatment history -

Seven sessions of hemodialysis were complete and the last session was on 24/08/2022

Treatment-

30/08/2022

31/08/2022

1/09/2022

Wednesday, 10 August 2022

36 year old female with fever, vomittings and abdominal pain

E-LOG GENERAL MEDICINE

Case scenario -

36 year old female, housewife by profession came to OPD with chief complaints of

fever since 1 week
Pain in the abdomen since 5 days
Vomiting since 3 days

History of presenting illness-

Patient was apparently asymptomatic 1 week back, then she developed fever which was associated with chills and rigor

This was followed by pain in abdomen which developed 5 days back in the epigastric region which was sudden in onset and it was dragging type

Vomiting since 3 days which was non bilious and non projectile - 5 to 6 episodes a day

History of past illness-

No history of DM, Hypertension, Tuberculosis, Asthma, Epilepsy

Hysterectomy was done 17 years ago

Personal History-

Married

Mixed diet

Bowel movements normal

Micturition normal

No known allergies

FAMILY HISTORY

- not significant

GENERAL EXAMINATION

- No - pallor /icterus / cyanosis / lymphadenopathy / clubbing

- BP - 90/80 mmg

- PR - 106 /min

-RR- 18 /min

- SPo2 -98% at RT

- Temp - 101 degree F

SYSTEMIC EXAMINATION

— CVS

- Thrills : No

- Cardiac sounds - S1 , S2 heard

- Cardiac murmurs : No

— RS

- Dyspnea : No

- Wheeze : No

- Position of Trachea : central

- Breath sounds : vesicular

— ABDOMEN

- Shape of abdomen : obese

- tenderness present , no palpable mass

- Hernial orrifices : Normal

- No fluids

- Liver and Spleen are not palpable

- Bowel sounds : yes

— CNS

- patient is conscious

- speech is normal

- No signs of meningeal irritation

- Higher motor functions intact

Investigations -

Provisional diagnosis -

Viral pyrexia

Treatment-

8/8/22

•IVF - 20 NS 10RL @75ml/hr

• Inj. Zoffer 4mg/IV/TID

• Tab. Naproxen 250 /TID

• Inj. Pcm 1g/IV/SOS if temp >=101F

•Tab. Pcm 650mg po/ TID

•Tab. Vertin 16mg po/ BD

9/8/22

•IVF - 10 NS 10RL @75ml/hr

• Inj. Zoffer 4mg/IV/TID

• Inj. pan 40mg po/OD

• Inj. Pcm 1g/IV/SOS if temp >=102F

•Tab. Pcm 650mg po/TD

•Tab. Vertin 16mg po/BD

• Inj. Monocef 1gm/IV/BD

• Syp. Cremaffin 10ml

10/8/22

•IVF - 10 NS 10RL @75ml/hr

• Inj. Zoffer 4mg/IV/TID

• Inj. pan 40mg po/OD

• Inj. Pcm 1g/IV/SOS if temp >102F

•Tab. Vertin 16mg po/BD

• Inj. Monocef 1gm/IV/BD

• Syp. Cremaffin 10ml

Monday, 8 August 2022

Gen med e log

E-LOG GENERAL MEDICINE

Hi, This is Moovika, a fifth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them.

A 66 YEAR OLD WITH END STAGE RENAL DISEASE

Chief complaints:

A 66 year old male hailed from suryapet presented to the OPD with chief complaints of:

Bilateral pedal edema since 3 months. SOB since 3 months. Puffiness of face. Body aches

HOPI:

Patients was apparently asymptomatic 12 years ago .

He developed chest pain and was diagnosed with IHD: S/P CABG was done.

At the same time he was diagnosed with hypertension and DM 2 for which he started taking medicine.

Then he was fine till 3 months back and started developing B/L pedal edema which is pitting type and was extended up to knees and Grade 2-3 SOB.

He went to hospital and was diagnosed with kidney disease .

Then he was planned for hemodialysis with right IJV.

1st dialysis on-23/07/22