Viswanath Garudadhri 


Roll no -147 , 8th sem 


 Under the guidance of Dr. Niteesh (intern) 


  This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission.


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 a diagnosis and treatment plan. 


CASE SCENARIO


     A 35 yr old male came to OPD with chief complaints of fever, pain in neck, cough, giddiness, lower back pain since 1 week. 


HISTORY OF PRESENTING ILLNESS


Patient was apparently asymptomatic 20yrs ago, then started drinking toddy and slowly addicted to whiskey since 2010. One month ago developed blood in stools and itching all over body. Patient experienced episode of loss of consciousness 10 days ago which was sudden. Later developed fever, cough, back pain since 7 days.

After admission into hospital, the patient experienced another episode of loss of consciousness which was 4 days ago.


HISTORY OF PAST ILLNESS 

History of alcoholic hepatitis 1 yr back


    Not a k/c/o DM, Asthma, Epilepsy, TB, HTN


TREATMENT HISTORY 

Baclofen

Supan-40

Lu-zine


PERSONAL HISTORY


Diet - Mixed

 Normal appetite

Sleep - Diminished

Bowel and bladder movements - normal

 Addictions - has been drinking toddy since 20 yrs.

Has been drinking whiskey since 2010

Last drink - 1/4/2023

No known allergies

History of blood transfusion twice

1st time - 8/4/2023

2nd time - 10/4/2023


FAMILY HISTORY

No data available


GENERAL EXAMINATIONS

Patient is concious, coherent and cooperative

Built - moderate

Nourishment - moderate

Pallor present 

    No -Icterus/Cyanosis/Clubbing/Lymphadenopathy/Edema/Malnutrition

Temperature -99 F

Pulse rate - 82 /min

Bp - 120/80 mm/hg

RR - 13cycles/min

SpO2 - 98%


SYSTEMIC EXAMINATION


CVS:  

No Thrills

Cardiac Sounds - S1, S2 +

No cardiac murmurs


RESPIRATORY SYSTEM: 

Dyspnoea - No

No Wheezing

Position of Trachea - central

Vesicular sounds 


ABDOMEN:

No palpable mass, No bruits

Liver Spleen - Not palpable


CNS:

Level of consciousness - conscious

Speech - Normal

No signs of meningeal irritation

Cranial nerves - Normal

No motor or sensory deficit

Glassgow scale -15/15








INVESTIGATIONS






PROVISIONAL DIAGNOSIS 




TREATMENT

Tab Dolo-650

Tab Lorazepam

Inj Pantaprazole

Inj Ceftriaxone

Inj Frusemide

Comments

Post a Comment

Popular posts from this blog

40 year old female

 This is an online E logbook to discuss our patients' 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 the available global online community of experts intending to solve those patients clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome A 40 year old female patient resident of Nalgonda, came to the General Medicine OPD with- CHIEF COMPLAINTS: C/o giddiness since 2 days C/o generalized weakness since 2 days C/o chest tightness and abdominal discomfort since 1 day HISTORY OF PRESENT ILLNESS: The patient was apparently asymptomatic 2 days back and then she started feeling weak and was not able to perform her daily tasks as she used to do before, and C/o: 1 day back, she felt giddy and weak in the morning wh...
Read more

COVID -19 PNEUMONIA

Image
Viswanath Garudadhri 3rd sem, roll no - 147 Under the guidance of Dr. Manasa ( intern)  This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission. 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 a diagnosis and treatment plan. CASE SCENARIO: A 63 yr old patient came to casuality with chief complaints of fever intermittent in nature associated with chills since one week and sob since 3 days. HISTORY OF PRESENT ILLNESS: Patient was asymptomatic 15 days back when he developed fever and generalised weakness, patient experienced sob since 3 days  Outside HRCT - 11/25 HISTORY OF PAST ILLNESS: N/K/C/O - DM, HTN TREATMENT HISTORY: No usage of drug as of now  PERSONAL HISTORY: Married Occupation - farmer Appetite - Normal  Non veget...
Read more

25 year old with dengue fever

Image
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 of a 25 year old female with body ache and fever This is a case of a 25 year old female, resident of nalgonda who is a homemaker, who presented to OPD 5 days ago with chief complaints of Generalised body ache since 10 days Pain in joints of hand and feet since 10 days Fever since 7 days History of presenting illness The patient was apparently asymptomatic 10 days ago when she developed generalised body ache which were sudden in onset, continuous, aggrevating with onset of fever...
Read more