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A 67 year old male patient e log

E-LOG GENERAL MEDICINE




Hi, This is K.Srinija , a eighth 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 67 year old male barber by occupation,resident of miryalaguda came to the opd with chief complaints of 

Shortness of breath since 1 week 

Fever since 4-5 days

HOPI :

-Pateint was asymptomatic 1 week back then he developed 

- shortness of breath which is of  grade 2-4 ,  aggrevating on doing work, walking and temporarily relieved on medication.       

-Fever since 4days which is of high grade , there is H/O  evening raise temperature associated with chills and rigors relieved by medication and increases again.

-H/O decreased urine output since 6 months

-C/o pain abdomen on &off left lumbar region since one week

-C/o Vomitings 2 days back 2-3 episodes, watery,non-projectile , non-biliary with food particles as contents

-C/o low stools 2-3 episodes 2 days back relieved now , watery , non-mucoid , non blood stained , no foul smelling

-C/o decrease in appetite since 1 week 

-No c/o of chest pain , palpitations 

PAST HISTORY

-He had history of hypertension since 10 years and on  medication 

TAB Olmesartan -H

-No history of diabetes, thyroid,epilepsy,asthma,CAD ,CVA 

-History of previous surgery Renal stunting 6 months back


PERSONEL HISTORY: 


-Diet:mixed

-Sleep:regular 

-Appetite: decreased appetite since 1 month 

-Bladder - decreased urine output with burning micturation since 1 month

-Bowel movements are regular 

-Addictions:he started taking chewable tobacco since 30 years and stopped one week back

-He also had a history of taking alcohol since 25 years and stopped one year back


Family history: Not significant


Treatment history: 

-Renal Stenting 6 months back


General examination::

Patient is conscious,cohorent , cooperative 

He is well built and moderately nourish

-Pallor present 



-Icterus: Absent 

-Cyanosis: Absent 

-Clubbing: Absent 

-Lymphadenopathy: absent 


VITALS:

-TEMP:97.2F

-PR:117bpm

-RR:28cpm

-BP:120/80

-Spo2: 94% @4L 02

-GRBS:128mg/dl


SYSTEMIC EXAMINATION:


RESPIRATORY SYSTEM:

-Patient examined in sitting position

Inspection:-

-Upper respiratory tract - oral cavity, nose & oropharynx appear normal. 

-Chest appears Bilaterally symmetrical & elliptical in shape

-Respiratory movements appear equal on both sides and it's Abdominothoracic type. 

-Trachea central in position & Nipples are in 5th Intercoastal space

-No dilated veins,sinuses, visible pulsations.


Palpation:-

-All inspiratory findings confirmed

-Trachea central in position

-Apical impulse in left 5th ICS, 1cm medial to mid clavicular line

-Infraclavicular- (NVBS) (NVBS)

-Mammary- (NVBS) (NVBS)

-Axillary- (NVBS) (NVBS)

-Infra axillary-(NVBS) (NVBS)                 

-Suprascapular- (NVBS) (NVBS)

-Interscapular- (NVBS) (NVBS)

-Infrascapular- (NVBS)(NVBS)


CVS: 

Inspection : 

-Shape of chest- elliptical 

-No engorged veins, scars, visible pulsations

Palpation :

-Apex beat can be palpable in 5th inter costal space

Auscultation : 

-S1,S2 are heard

-no murmurs


PER ABDOMEN






-Shape of abdomen-scaphoid

-Tenderness-No

- Palpable mass-No

- Liver- Not palpable

-Spleen - Not palpable

-Bowel sounds - Normal


Provisional Daignosis: left hydroneprosis secondary to ? left ureteric obstruction ? Post renal AKI


Investigations:












Treatment:

1.INJ LASIX 40 MG IV STAT

2.NEB WITH DUOLIN STAT  BUDECORT

3.INJ NEOMOL 1GM IV SOS

4.TAB DOLO 650MG PO/BD

5.TAB OLMESARTAN-H PO/BD

6.BP,PR,TEMP CHARTING 4TH HOURLY.



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