GENERAL MEDICINE E-log

NAME: A Sanvith

ROLL NO: 09

This is an 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. 

CHIEF COMPLAINT:

A 78yrs old male carpenter by occupation came to opd with chief complaints of 

Pain abdomen (left side)

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 week then he had a complaint of tonic movements of both upper and lower limbs which are of 3 to 4 episodes of duration 5 mins.He also had a complaint of post ictal confusion of duration 20-30 mins and also complaint of tongue bite.

Then he had a complaint of chest pain on the left side since 3 days ,the pain is not radiating.

No h/o cough,fever,SOB,headache,sudden onset,blurring of vision




HISTORY OF PAST ILLNESS:

N/K/c/o:DM,HTN,Asthama,TB,Epilepsy.

H/o of TURP surgery for BPH.

FAMILY HISTORY:

No significant family history

PERSONAL HISTORY:

  • Married
  • Appetite is normal
  • Mixed diet
  • Bowels regular
  • Normal micturation
  • No known allergies
  • Alcohol intake is present
  • Known smoker
  • No other habits or addictions present

GENERAL EXAMINATION 

Patient is conscious, coherent 

Absence of pallor,icterus,clubbing,cyanosis,lymphadenopathy,pedal edema.

VITALS

1.Temperature:Afebrile

2.Pulse:75/min

3.Respiratory Rate:22

4.BP:120/80mm/hg

5.SPO2:85

6.GRBS:126mg%

SYSTEMIC EXAMINATION :

CARDIOVASCULAR SYSTEM:

  • S1 and S2 heard
  • No thrills and murmurs

RESPIRATORY SYSTEM:

  • Normal vesicular breath sounds
  • Position of trachea is central
  • Dyspnea is absent 
  • No wheeze

EXAMINATION OF ABDOMEN:

  • Shape- scaphoid
  • No tenderness
  • No palpable pass
  • Normal hernial orifices 
  • No free fluid
  • No Bruits
  • Liver is not palpable
  • spleen is not palpable
  • Bowel sounds heard

CENTRAL NERVOUS SYSTEM:

  • Patient is conscious 
  • Speech is normal 
  • No focal neurological defect
  • All reflexes were present 
  • Absence of cerebral signs
INVESTIGATION :




















 


21/06/2022







PROVISIONAL DIAGNOSIS
Seizures
Pneumonia?

Comments

Post a Comment

Popular posts from this blog

GENERAL MEDICINE E-log

Image
 NAME : A SANVITH ROLL NO : 09 This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan. DOA: 24/06/2022 Question : A 38 year old male farmer by occupation and came to the opd with chief complaints of pain on the right leg. HISTORY OF PRESENT ILLNESS Patient was asymptomatic one month back and he devoloped pain on the Right leg which is slow in Onset and he visited RMP doctor and Doctor gave medicine the Onset Of Pain is increased and he visited sparsha  hospital and doctor suggested to take x-ray and MRI scan and he gave medicines the patient decreased p ain with medicine  and he devoloped lot of Pain and  went to homeopathy 1 month back and with medic
Read more

GENERAL MEDICINE E-log

Image
NAME:A sanvith ROLL NO:09  Welcome and greetings to every one who are visiting my blog. This is A sanvith of 8th semester.  This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan. CHIEF COMPLAINTS : Generalized weakness since 1year Premature ejaculation since 1year. HISTORY OF PRESENTING ILLNESS : Patient was apparently asymptomatic 1year back and then he developed weakness associated with semen in urine. And also developed polyuria(nocturia two to three times at night) patient also history has h/o premature ejaculation 2-3minutes since 1year. HISTORY OF PAST ILLNESS :  Patient was  n/k/c/o go fever, pain abdomen, burning micturition, vomitings,loose
Read more

GENERAL MEDICINE E-log

Image
 NAME : A SANVITH ROLL NO : 09 DATE OF ADMISSION:29/06/2022 This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan. QUESTION  A 57 year old male patient came to the hospital with cheif complaints of fever since 6days and pain abdomen since 4days History of present illness  Patient was apparently asymptomatic 6days back then he developed fever which is intermittent type (morning and night) and 4days back he developed severe pain in abdomen in epigastric and right hypochondrium region and nausea after 2hours of dinner not associated with vomitings and cough for which he admitted in hospital early morning where symptoms are not subsided and therefore cam
Read more