40 Akshara kruthi , 5th sem
This elog depicts the patient -centered approach to learning . This is an online E log book recorded to discuss and comprehend our patients de-identified health data shared , after taking his /her /guardians signed informed consent . This elog also reflects patients centered learning portfolio.
Date of admission : 27/07/2022
CASE
A 46 year old male patient, farmer by occupation, resident of nalgonda came with chief complaints of
1. Shortness of breath since 6years
2.Cough since 4years which is on and off
3. Pedal oedema and facial puffiness since 3years.
4. Abdominal distension since 3years.
5. Hard stools since 10 days.
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 6years ago. Then he developed shortness of breath which was initially grade 1 and gradually progressed to grade 2 . Cough since 4 years (on and off) which is productive with yellow colored sputum. Then he developed abdominal distension , pedal oedema and since puffiness 3years back. For which he visited a hospital in miryalaguda 3years back and it relieved on medication for 1 yr and again reappeared 2years back .Hard stools since 10 days.
He wakes up at 5AM in the morning and works in the animal shed like cleaning the shed, and does his breakfast at 10AM and goes to herd his sheeps and comes back home at 6PM,skips his lunch and have his dinner at 9PM in the night and goes to sleep at 10PM.
HISTORY OF PAST ILLNESS
Not a known case of HTN, DM, TB, epilepsy, CAD.
PERSONAL HISTORY
Marital status : Married
Occupation : Shepherd and farmer
Diet : mixed
Appetite : Normal
Sleep : not adequate
Bowel movements : irregular (hard stools since 10 days)
Micturition : normal
Addictions
Alcohol : Regular since 30 yrs (stopped drinking since April 2022)
Tobacco : smoking (1 pack of beedi /day since 30 yrs )
He has no known Allergies.
TREATMENT HISTORY
Cataract was done 1year ago in left eye.
FAMILY HISTORY
No significant family history.
DRUG HISTORY
Not Significant
GENERAL EXAMINATION
Patient is conscious , coherent , cooperative and examined in a well lit room.
VITALS
Pulse Rate: 88/min
Blood pressure:130/70mmHg
Respiratory rate:
Temperature : 98.6°F
Spo2 : 98%
GRBS : 205mg%
PHYSICAL EXAMINATION
Pallor : absent
Icterus : absent
Cyanosis : absent
Clubbing of fingers and toes : absent
Lymphadenopathy : absent
Edema : Bilateral pitting type of Pedal oedema present
Malnutrition : absent
Dehydration : absent
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
S1 and S2 are heard
No thrills
No murmurs
RESPIRATORY SYSTEM
Dyspnea : present
Wheezing : present
Trachea : central
Vesicular breath sounds : Normal
PER ABDOMEN:
INSPECTION
Distended shaped abdomen
Hernial orifices : Umbilical hernia present(umbilicus is everted)
No visible pulsations
Caput medusae : present
PALPATION
NO Tenderness in any quadrants of abdomen, liver and spleen.
Liver and spleen - not palpable
No palpable mass
PERCUSSION
Shifting dullness - present
Free fluid -?present
Fluid thrill : absent
AUSCULTATION
Bowel sounds : present
No bruits
CNS
Conscious
Speech : Normal
No signs of meningeal irritation
Cranial nerves : intact
Motor system : Normal
Sensory system : Normal
Reflexes : Normal
Investigations :
USG
ECG
PROVISIONAL DIAGNOSIS
Chronic liver disease?
Heart failure?
TREATMENTOn 27/7/2022
INJ. LASIX 40mg IV/
Neb. Duolin 8th hour
Neb. Budecort 8th hour
On 28/7/20
Inj. Lasix 40mg IV/
Neb. Duolin 8th hour
Neb. Budecort 12th hour
Tab. Azithromycin 500mg PO/
Tab. Montac LC /PO/
Tab. Metformin 500mg PO/
On 29/7/20
Inj. Lasix 40mg IV/
Neb: Duolin 8th hour
Neb: Budecort 12th hourl
Tab. Azithromycin 500mg PO/
Tab. Montac LC PO/
Tab. Metformin 500mg PO/ODODODy lyBD22ODODODlylyBD22lylyBD
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