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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