General Medicine - 2

July 09, 2022

A 47 YEAR OLD MALE PATIENT CAME TO OPD WITH VOMITINGS AND DECREASED URINE OUTPUT.

Hi, we are Dussa Sri Snehitha and Gugulothu Soniya, 3rd sem medical students.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.


CASE SHEET:

CHIEF COMPLAINTS: 

A 47 year old male patient, driver by occupation, hailing from Haliya, came to causality with chief complaints of:
-vomitings for 1 day(20-30 episodes)
-decreased urine output for 1 day

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic a 4 days ago. The pateint is known case of severe alcohol intake. Later on, he has decreased appetite. He hadn't taken any food for last 4 days.

 Later on, the patient  had severe vomitings 20 to 30 episodes. The vomiting is watery in nature with no colour.

The patient have complaints of constipation for 3 days. He also had pain in the abdomen for 2 days.

Then the patient also have complaints of deceased urine output to that extent where he didn't void any urine for last 24 hours.

He also has shortness of breath in the morning and increased thirst since today morning. There are no other complaints of chest pain, cough, fever.

ASSOCIATED DISEASES:
The patient is known case of hypertension for 3 years for which he is taking medication regularly.

PAST HISTORY:
He  has a history of acute appendicitis 3 years ago.

PERSONAL HISTORY:

Diet : Mixed
Bowel: Constipation
Micturition: decreased
Appetite : decreased
Habits: Alcoholic for past 10 years (90-180ml/day)
No history of allergy, asthma, tuberculosis, epilepsy, coronary heart diseases.

FAMILY HISTORY:
No family history

DRUG HISTORY:
Metoprolol - 25 mg O.D.

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative
No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No malnutrition
No pedal edema
Severe dehydration 

Vitals:

B.P. : 90/60 mm of Hg

Temperature : 98 F

Pulse: 70 beats / min

SPO2 : 98% 

SYSTEMIC EXAMINATION:

Cardiovascular System:
 Sounds heard: S1 and S2
No thrills are heard
No murumurs

Respiratory system:

Breath sounds : vesicular sounds
No dyspnea
No wheezing

ABDOMEN:

Shape  of abdomen: normal
Tenderness : present - right iliac fossa
No palpable mass
No bruits
Non palpable liver
Non palpable spleen
Bowel sounds : heard

CENTRAL NERVOUS SYSTEM:

Conscious
Speech-normal

INVESTIGATIONS:
 LFT:
Blood sugar:
Ultrasound report:
Complete blood picture:

PROVISIONAL DIAGNOSIS :

Acute pancreatitis,  acute gastritis, severe metabolic acidosis , hypotension,  acute kidney injury.
 Medications given:














Comments

Post a Comment

Popular posts from this blog

General Medicine -17

A 22 YEAR OLD MALE CAME WITH THE CHIEF COMPLAINTS OF FEVER, COUGH AND RUNNING NOSE. This is an online E log book by D.Sri Snehitha and Ebrahim Badshah to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed 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-centred online learning portfolio and your valuable comments on comment box is welcome. 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 a diagnosis and treatment plan.  CHIEF COMPLAINTS: A 22 year old male student came with the...
Read more

General Medicine - 19

Image
A 70 YEAR OLD MALE CAME TO OPD WITH BILATERAL PEDAL EDEMA This is an online E log book by D.SRI SNEHITHA to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed 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-centred online learning portfolio and your valuable comments on comment box is welcome. 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 a diagnosis and treatment plan.  CHIEF COMPLAINTS: A 70 year old male came with the chief complaints of:  - swelling of both feet since...
Read more

General Medicine -14

Image
A 26 YEAR OLD FEMALE CAME WITH SHORTNESS OF BREATH AND CHEST PAIN. This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed 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-centred online learning portfolio and your valuable comments on comment box is welcome. 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 a diagnosis and treatment plan.  CASE SHEET: Chief complaints: A 26 year old female, hailing from nakerekal, agricultural worker by oc...
Read more