GENERAL MEDICINE CASE DISCUSSION.

 4 January 2023

General medicine case discussion

E LOG MEDICINE CASE

04/01/2023

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 comeup with Diagnosis and Treatment plan.

A 45year old male farmer by occupation came to general medicine OP with chief complaints of abdominal swelling along with stiffness. 

History of present illness:

Patient was apparently 16 days back when he had consumed excess alcohol without taking any food. Next day morning he observed his abdomen was swollen with tightness. He also mentioned that there was pain in the abdomen with irregular bowel movements. He mention he also had a few episodes of vomitings. No history of fever. 

Past History:

No history of HTN, DM, TB, EPILEPSY, CAD

No history of surgeries. 

Family History:

No significant family history. 

Personal History:

Appetite: normal

Diet: Mixed

Bladder habits: regular

Bowel moments: irregular

Sleep: normal

Addictions: Alcohol(1l/day), Betel leaf

Known Allergies: nil 

General Examination:

Conscious, coherent, and co-operative. 

Moderately built and nourished. 

Pallor: absent

Icterus: present

Cyanosis: absent

Clubbing of fingers: absent

Lymphadenopathy: absent

Pedal edema: present

Vitals:

Temperature: 97.8 degrees Celsius

Pulse rate: 82 beats per min

Respiratory rate: 16

BP: 100/70

SPO2: 96%

GRBS: 100mg% 

Systemic Examination:

A. CVS

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

B. Respiratory system:

1. Dyspnea: absent
2. Position of trachea: center
3. Normal vesicular breath sounds are heard
4. No wheezing. 

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: 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. Reflex’s - ++
10. Cerebeilar signs: Finger nose- in coordination, Knee heel - in coordination

Investigations:

Provisional Diagnosis: 

Jaundice with SIRS, MODS secondary to leptospirosis

Treatment: