51M with SOB

Hello all this is G Jagadeesh,a eight semester student.This E Log depicts the patient centered approach to learning 

This is an an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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

CHIEF COMPLAINTS :

A 51M farmer by occupation , resident of nalgonda came to opd with c/o shortness of breath since 2 months and bleeding per rectum since 2 months .


HOPI 

Patient was apparently asymptomatic 2 months ago then he developed SOB of insidious onset, gradually progressive increasing in intensity since 2 months (Glade II- III)

The patient had undergone surgery for Haemorrhoids 2 years ago , and then ,there was relapse of Haemorrhoids again 2 months ago and he was losing blood in an amount of 30ml/day during passing of stools

No h/o constipation , nausea , vomiting ,burning micturation .


PAST HISTORY :

N/KC/O DM , HTN , CAD , CVA , EPILEPSY , THYROID DISORDERS 


FAMILY HISTORY : 

not significant 


PERSONAL HISTORY : 

Decreased appetite 

Mixed diet 

Decreased bowel movements 

Normal micturition 

Addictions : consumes alcohol regularly from 2 years


GENERAL EXAMINATION :

I have examined the patient after taking prior consent and informing the patient in the presence of a attendant. The examination was done in both supine and sitting position in a well lit room. 


- patient was conscious, coherent and cooperative

- well oriented to time, place and person

- well built and adequately nourished

- pallor present 




- icterus present



- no cyanosis 

- no clubbing of fingers

- no lymphadenopathy 

- no pedal edema

- koilonychia present




VITALS :

Temperature :  afebrile

BP :  100/70 mmhg                       

Pulse rate : 100/min

Respiratory rate : 16/min

SPO2 : 98% RA


SYSTEMIC EXAMINATION :

CVS : 

S1S2 +

Cardiac murmurs heard

No thrills

RS : 

Position of Trachea - central

BAE +

NVBS +

P/A :

Soft , Non tender

CNS :

NFND


INVESTIGATIONS :

18/10/2023











PROVISIONAL DIAGNOSIS: 

Anemia secondary to blood loss due to haemorrhoids


TREATMENT :

1) TAB.OROFER - XT PO/OD

2)TAB.LIMCEE - PO/OD

3)TAB.MVT - PO/OD



Comments

Post a Comment

Popular posts from this blog

54M with fever and SOB

Image
Hello all this is G Jagadeesh,a eight semester student.This E Log depicts the patient centered approach to learning   This is an an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. have 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 The patient/ attender was informed the purpose of the information being acquired. An informe...
Read more

Renal failure

Image
 Hello all this is G Jagadeesh,a fifth semester student.This E Log depicts the patient centered approach to learning. This is an online E Logbook recorded to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent. Date of admission : 4/7/22  A 65 year old male patient came to medical OPD with Chief complaints of 1) Generalised Swelling and 2) Decreased urine output Since 10 days  History of presenting illness  patient was apparently assymptomatic 4 years back and then developed pain abdomen. At that time he was diagnosed as having Renal calculi and underwent percutaneous Neprolithotomy in our hospital and later got discharged.Later he developed generalised weakness and dizziness for which he was diagnosed as having diabetes mellitus and Hypertension 2 years back.He was on irregular medication for this unresponsive behaviour he was in Icu for 4-5 days and diagnosed to be hypoglycemia 2years back a...
Read more

70M with SOB and cough

Image
Hello all this is G Jagadeesh,a eight semester student.This E Log depicts the patient centered approach to learning   This is an an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have 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 The patient/ attender was informed the purpose of the information being acquired. An infor...
Read more