GENERAL MEDICINE CASE DISCUSSION.

27 DECEMBER 2022

General medicine case discussion

E LOG MEDICINE CASE

27/12/2022

This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed 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 protfolio and your valuable inputs on comment box is welcome.

Name: Kondakindi Vrithika Reddy

Roll no : 59

2020 Batch

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.

Date of admission 18/12/2022

A 70year old male farmer by occupation came to general medicine OPD with chief complaints of blood splits since three days, cough and chest pain. 

History of present illness: 

Daily routine before presenting to hospital :

We wakes up 6am, then around 7am he drinks tea and around 8am he takes his breakfast. He eats his lunch at around 1pm. In the evening around 5pm he takes another cup of tea. He finishes his day my eating dinner around 8pm. 

Recently before coming to the hospital: 

The patient was apparently asymptomatic 1 months back then developed cough with sputum and chest pain, shortness of breath since 20days and blood splits since three days that are not accompanied with cough. No clots are seen in blood splits 

No complaint of fever and chest pain. 

Past history:

He has a history of cough and chest pain 5 years ago which was relieved on taking prescribed medications. 

Not a known case of diabetes, hypertension, coronary artery disease, epilepsy, tuberculosis. 

No history of blood transfusions 

No history of surgeries. 

Personal History:

Appetite: normal

Diet: Mixed

Bladder habits: regular

Bowel moments: regular

Addictions: Alcohol regular, Smoking history of 2 Beedi packs in the past and 1 Needi pack since last 2 years. 

No significant family history. 

General Examination:

Conscious, coherent, and co-operative. 

Moderately built and nourished. 

Pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing of fingers: absent

Lymphadenopathy: absent

Pedal edema: absent

Vitals:

Temperature: 99 degrees Fahrenheit 

Pulse rate: 94 beats per min

Respiratory rate: 22 cycles per min

BP: 100/90mm of Hg 

SPO2: 100%

GRBS: 95mg% 

Systemic Examination:

A. CVS

1. S1 and S2 sounds heard
2. No audible mummers
3. No trills

B. Respiratory system:

1. Inspection: 

• Shape of chest elliptical 
• Bilaterally symmetrical chest
• Trachea centrally placed
• Apical impulse couldn’t be seen

1. Palpation:

• No local rise in temperature 
• No tenderness
• Chest movement equal on both sides

1. Percussion:

• Direct resonant
• Indirect resonant

1. Auscultation:

• Normal breath sounds: both sides, type of breathing.

C. Per-abdomen:

1. Scaphoid shaped abdomen
2. No visible swellings 
3. No visible scars and injuries
4. No tenderness
5. No palpable mass 
6. Bowel sounds: not heard

D. CNS:

1. Conscious 
2. Speech- normal
3. Signs of meningeal irritation - Nil
4. No neck stiffness
5. No kerming's sign
6. Cranial system - intact 
7. Motor system - intact 
8. Sensory system - intact 
9. Cerebeilar signs: Finger nose- in coordination, Knee heel - in coordination

Investigations:

Provisional Diagnosis: COPD

Treatment: 

1. O2INHALATION WITH NASAL PRONGS WITH 1-2 LTS 02 IF SP02<95%
2. INJ. CEFTRIAXONE 1 GM/IV/BD 7days
3. INJ.PAN 40MG/IV/BD
4. TAB.ETHAMSYLATE 250MG PO BD
5. INJ.TRANEXA 500MG/IV/STAT
6. SYP.ARISTOZYME 2 TSP BD
7. MONITOR VITALS PR, BP,RR,SPO2
8. SYP.GRILLINCTUS 2 TSP PO TID
9. TAB,MVT PO OD
10. INJ HYDROCORTISONE 100MG/IV/STAT 3days