Generalmedicine case discussion
GENERAL MEDICINE CASE DISCUSSION
A case of 60 yr old female with a chief complaint of SOB
N.VISHNU ROHITH REDDY
ROLL NO:98
9th semister
This is 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 patients 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 comment box is welcome .
I’ve 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.
CASE DISCUSSION
A 60 yrs old female patient presented with chief complaints;
SOB grade 3-4 from past 5days progressive in character,no diurnal variation
Cough along with SOB , history of cough from past 3 months
HOPI: patient was apparently asymptomatic 10yrs back then she had episode of shortness of breath with cough expectoration and was taken to hospital reduced after 2-3 days
She had intermittent episode of acute expectoration yearly 2-3 times for which she has to be hospitalized
PAST HISTORY:
-History of similar complaint 6 yrs back for which treatment taken
-History of CAD
She also gave a long history of usage of bio fuel since childhood and still uses now and then
--She is a known case of diabetes since 3yrs for which medication is being taken
not a k/c/o: HTN, Asthma, epilepsy, CAD,TB
TREATMENT HISTORY
Diabetes medication since 3yrs
PERSONAL HISTORY:
Appetite- normal
Non vegetarian
Bowels & bladder - reduced frequency of passing stools
Alcohol- occasional
FAMILY HISTORY:
No history of similar complaint in family members
GENERAL EXAMINATION
Patient was examined in a well lit room, after taking informed consent.
conscious, coherent, cooperative, well-nourished, well -oriented to time, place, person
Pallor: yes
Icterus: no
Cyanosis: no
Lymphadenopathy: no
Edema: yes
Clubbing of fingers: yes
vitals:
temperature:98.4 degree Fahrenheit
RR:30/min
PR:110/min
BP:130/80mm Hg
Spo2:90%
SYSTEMIC EXAMINATION:
CVS: S1 & S2 heard
no murmurs and cardiac thrills
RESPIRATORT SYSTEM:
dyspnoea - yes
wheeze - yes
position of trachea is central
Crepitus heard in all lung fields
ABDOMEN:
Inspection
the shape of the abdomen: distended
palpation;
Tenderness- not present
no palpable mass
Bowel sounds: not heard
liver and spleen not palpable
CENTRAL NERVOUS SYSTEM:
consciousness- conscious
Speech- normal
Neck stiffness-no
Kerning sign -no
Giat- normal
Sensory and motor system- intact
INVESTIGATION:
USG:moderate hepatomegaly with grade 1 fatty liver
X-Ray:
ABG,LFT:
ECG:
PROVISIONAL DIAGNOSIS:
Chronic bronchitis,acute exacerbation of COPD,with uncontrolled type 2 DM and old coronary artery disease
2)Neb with Foracart 8th hrly
3)TAB Augmentin 625MG PO/ TID
4)Inj insulin s/c
5)Tab PCM 650mg/po/sos
6)Syp Ascoril D.po.bd
7)Vitals monitoring
8 GRBS monitoring 6 hrly
9 I/o charting
