GM case with sob and pain abdomen

 A 64 YR M WITH SOB AND PAIN ABDOMEN 

june 07,2023

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.


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. 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.


A 64 years old male patient barber by occupation came to casuality with chief complaints of  shortness of breath and pain in abdomen 


History of presenting illness::

Patient was apparently asymptomatic 1 month back and then he developed shortness of breath incidious onset and gradually progressive 

No c/o chest pain,Palpations

C/o fever for 3-4days ,high grade, evening rise of temperature associated with chills and rigor

Since one month patient complaints of breathlessness (grade 3) insidious in onset gradually progressive aggrevated on walking and no seasonal variation. 


Past History::

Decreased urine output since 6 months 

c/o pain abdomen on left lumbar region since 1 week 

patient is a known case of HTN since 10 years for which he is on medication (olmosetron tab)

Not a known case of DM,TB,ASTHMA 

Personal history:

Apettite-decreased

Diet- mixed

Bladder- decreased

Bowel -abnormal

##Addictions- 

Tobacco chewing-stopped 3 yrs back

Alchol-stopped 1yr ago

Family history: 

No significant


Treatment 

Renal stenting has done


General examination::

Patient is conscious,cohorent , cooperative well known with time, place, person 

He is well built and moderately nourish

No pallor 

No Lymphadenopathy

No pedal oedema 

No icterus cyanosis, clubbing.


VITALS :

Temp : 98.9

Pulse rate-117

Blood pressure :120/70mmhg

Respiratory rate :20 cpm

Spo2 : 90%


SYSTEMIC EXAMINATION:


Respiratory system:

Inspection: chest shape normal, 

Breath sounds -vesicular

Dyspnea: present 

Palpation: trachea -central


MANAGEMENT :


INVESTIGATIONS :  

CBP


Ultra sound scan of abdomen

Biochemical investigation


Provisional :post rena Aki,hydronephrosis


Treatment: 





Comments

Post a Comment

Popular posts from this blog

GM CASE WITH FEVER AND CHILLS

Image
 A 65 yr old male with fever and chills June 08,2023 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. 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. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here...
Read more

82 YR OLD FEMALE WITH BILATERAL LOWER LIMB WEAKNESS AND PEDAL OEDEMA

Image
82 year old female with B/l lower limb weakness and pedal edema. on June 21, 2023 This is an online elog documenting de-identified patient health data after taking his signed consent to enforce a greater patient centered learning.  DEIDENTIFICATION -  The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever. CASE DISCUSSION - 82 year old female patient came with C/O weakness of lower limb, Neck and shoulder pain since along with pedal oedema and fever since 10 days. HOPI - Patient was apparently asymptomatic 10 days back then she developed weakness of the lower limbs, sudden in onset, non-progressive.  Also, C/O fever since 10 days low-grade not associated with chills and rigours, continuous, relieved on medication. C/O pedal oedema since 10 days, pitting type, from ankle to knee. No C/o chest pain, palpitations, cough, cold, LOC PAST HISTORY- K/c/o of HTN since 10 years(On medication- Telma 40mg) No...
Read more

35 yr M/with pain abdomen and Dyspnea

Image
ALCOHOLIC LIVER DISEASE  June 06, 2023 Hi, Iam Gopi of 5th semester medical student.This is an online e block to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio.  A 35 years old male patient carpenter by occupation is a resident of suryapet came to medical OPD with complaints of pain in the abdomen And Dyspnea.  CHEIF COMPLAINTS: Pain in the abdomen since 3 months Occasional palpitations since 3 months shortness of breath since 1 month Generalized weakness since 10 days.  History of presenting illness: patient was apparently asymptomatic 3 months ago then he Started developing palpitaions which were not associated with chest pain which is reduced on drinking alcohol. There is SOB which is of GRADE - 2 Without association of orthopnea and PND Pain is sudden  in onset, non radiating , no aggregating on consumption of food or during an activity, no relievin...
Read more