General Medicine Ward Case:

THURSDAY,JUNE 30 ,2022

18 ANANYA


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-centered online learning portfolio and your valuable inputs on the comment box.


A 36 year old male patient from valigonda driver by occupation came to hospital on June 29 evening with chief complaints of

 .Pain in abdomen since 1 week


.bilateral pedal edema(pitting type)since 1week


.Sob on exertion since 5months, no c/o chest pain,palpitations


.nausea(post meals intake)since 20 days


.decreased appetite since 20 days

. Loose stools(no blood) since 10 days ( subsided)

.Generalised weakness since 1 month

History of present illness 

Patient has pain in the abdomen and has bilateral pedal edema since 1 week 


He also has sob on exertion which has been showing up.since 5 months which is associated with nausea , loose stools and generalised weakness . 


HISTORY OF PAST ILLNESS 

He was diagnosed with diabetes since 1 year


Personal history:

Appetite - decreased 

Bowel - diarrhoea 

Micturition-normal

Diet- mixed

Addictions- alcoholic since 20 years, smoker


Family history: no history of any illness


Physical examination:

Icterus: present 

Pallor:none

Cyanosis:none

Clubbing:none


Temperature :a febrile

Malnutrition-yes

Oedema of feet:





ViTALS

Pulse rate- 84/min

Respiration- 18 cycles/min

BP Lt 100/70Arm mm/Hg

GRBS 98mg%

SPO2:99%



SYSTEMIC EXAMINATION.           

cvs:

s1 and s2 heard and no murmurs heard.

 RESPIRATORY SYSTEM :

 Dyspnoea - yes

Breath sounds -vesicular

Wheeze -no


 Abdomen:

Shape of abdomen -distended

Tenderness - no

Bowel sounds -yes

CNS: 

no focal neurological defect seen.


Investigations:


Usg Abdomen:

LFT

CBP
CUE
blood sugar-random

blood urea
Serum creatinine 
ECG:


PROVISONAL  DIAGNOSIS-

chronic liver disease 

Chronic pancreatitis 

Prostatic abscess. 


TREATMENT:

1.inj. PIPTAZ 4.5 gm/iv/tid

2.inj.PAN 40 mg/iv/od













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