General Medicine -1
July 05, 2022
Biochemical investigations:
PROVISIONAL DIAGNOSIS :
A 34 YEAR OLD MALE PATIENT CAME WITH SHORTNESS OF BREATH ON EXERTION AND LOSE STOOLS.
Hi,Iam Dussa Sri Snehitha, 3rd sem medical student.This is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.
A 30 year old male, driver by occupation, came to causality with chief complaints of
-Shortness of breath during exertion for
5 months
- nausea(post meal) for 20 days
- loose stools (no blood) for 10 days
HISTORY OF PRESENT ILLNESS
The patient was asymptomatic 5 months ago. Later on, he observed shortness of breath while exertion for which he hadn't taken any medication.
Patient also complained of generalised weakness and body pains for 1 month.
He developed nausea immediately after meals and decreased appetite since 20 days.Later on he developed pedal edema a week ago. He also complained of loose stools for 10 days(15 episodes per day).
He developed fever for 3 days which was intermittent. Fever subsided by medication with paracetamol.
He is a known alcoholic for 20 years (360ml/ day). He stopped his alcohol intake 20 days ago. He is also a known smoker for 20 years. He stopped smoking 3 days ago after admitting in the hospital.
ASSOCIATED DISEASES:
The pateint is a known case of type II Diabetes Mellitus for which he has been using medication of orally administered antihyperglycemic agents regularly.
PAST HISTORY:
No history of any accidents or surgeries
PERSONAL HISTORY:
Diet: mixed
Bowel: irregular
Micturition: normal
Appetite: decreased
Habits: alcoholic and smoker for 20 years
No history of allergy, asthma, epilepsy, hypertension, tuberculosis, coronary artery diseases.
FAMILY HISTORY:
No family history.
GENERAL EXAMINATION:
Patient is conscious,coherent and cooperative
B.P. :110/70mm of Hg
Pulse rate: 84 beats/min.
Respiratory rate: 18 cycles/min.
Temperature: afebrile
No pallor
No cyanosis
No clubbing
No lymphadenopathy
No dehydration
Icterus is present
Malnutrition is seen
Pedal edema: pitting type, below the ankle since a week
SYSTEMIC EXAMINATION:
CVS: S1, S2 cardiac sounds heard, no murumurs, no thrills
RS: no dyspnea, no wheezing, vesicular breath sounds are heard.
Abdomen: distended abdomen
Bowel sounds are present
Non palpable liver, spleen
Non palpable mass
CNS: consciousness
speech-normal
INVESTIGATIONS:
LFT
Complete blood picture:
Urine examination:
Bacterial culture:
ECG:
For different leads:
PROVISIONAL DIAGNOSIS :
Chronic liver disease, acute pancreatitis, prostatic abscess.
On Medication of:
TODAY'S UPDATE: 6 July, 2022
Patient is coherent and cooperative.
Patient's condition was better.
Has increased appetite than previous.
On Medication with insulin injection and pain killers.
TODAY'S UPDATE: 7July, 2022
Patient is conscious and coherent.
Patient is recovered from pains.
On Medication with insulin injection in the morning at 9a.m.
Has increased appetite than previous.
Micturition is regular.
Bowels are regular.
Pedal edema is subsided little, than previous, but not completely.
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