General medicine case-3

8/10/21

This is 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.

A 70 year old female resident of narayanpur came to causality with chief complaint of shortness of breath and cough since 5 days.

History of present illness :-
Patient was apparently asymptomatic 5 days back then she noticed shortness of breath from 5 days .Patient also has cough with expectoration. Scanty sputum is present. 
No h/o fever.
No h/o chest pain.
No h/o pedal edema.
No h/o decreased urine output.

Past History:-
Patient is a known case of hypertension since 5 years taking on  regular medication. 

Personal history:-
Patient has normal eating habit with mixed diet.
Loss of weight .
Loss of apetite.
Regular bowel and bladder movements. 
No addictions.

General examination:-
Patient is conscious,coherent,cooperative .
Malnutrition +
No pallor,icterus,cyanosis,clubbing,
lymphadenopathy,edema.

VITALS : 
Temp: 98.7 F
PR: 60 bpm 
BP: 110/70 mm hg 
RR: 18 cpm  
Spo2 - 98%

CVS : 
S1, S2 heard , No murmurs 

Respiratory system: 
Position of trachea: central 
Dyspnoea present
Wheeze present 
BAE present decreased in rt side 

PER ABDOMEN: Soft,non tender

CNS: 
Patient is Conscious ,oriented to time,place and person .
Motor & sensory system: normal 
Reflexes: present 
Cranial nerves: intact 
No meningeal signs .
Liver function test:-
Total biluribin:-1.38mg/dl
Direct biluribin:-0.29mg/dl
SGOT(AST):-31 IU/L
SGPT(ALT):-16 IU/L
Alkaline phoshatase:-163 IU/L
Total proteins:-5.7 gm/dl
Albumin:-3.2gm/dl

Serum electrolytes:-
Sodium-133 meq/L
Potassium-4.4 mEq/L 
Chloride-97 mEq/L 

Serum creatinine:-2.5 mg/dl

Blood urea:-122mg/dl

Urine sodium:-180 m mol/L
Urine potassium:-14.0
Urine chloride :-212 m mol/L

ESR:-90 mm/1st one hour

Provisional diagnosis:-
PRE RENAL AKI WITH COPD.

Questions:-
Why was sudden onset of sob seen in this patient?
What might be the cause for copd in this patient?Is hypertension a cause for copd?


Popular posts from this blog

General medicine case-2

Image
21 /09/2021 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. A 65 year old Male,resident of  Rajamalkapur toddy climber by occupation  presented to causality with chief complaint of sudden onset of unable to stand ,unable to sit,unable to lift the head from pillow since 10 days which is associated with neck pain and backache . History of present illness :- Patient was apparently asymptomatic 10 days back ,then he had generalized weakness,neck pain,backache,pain while raising the legs associated with decrease sensation righ...
Read more

Final practicals-Long case-1802102002

Image
This is 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. A 65 year old male patient toddy tree climber by occupation came to our hospital on 2nd February with chief complaints of absence of urine output (anuria)since 1 day and shortness of breath since 1 day. History of present illness:- Patient was apparently asymptomatic 15 years back ,then he suddenly fell from toddy tree  while climbing ,then he had fracture of femur for which open reduction and internal fixation(ORIF) was done. Patient had got flexion fixed deformities since 7 years. Patient is unable lie down flat ,he is unable to put his neck on pillow since 7 years. Patient stays at home  and stopped drinking ...
Read more

Final practicals-Short case:1802102002

Image
This is an online E- log book to discuss our patient's de- identified health data shared informed 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 comment box is welcome." A 36 year old male patient farmer by occupation came to our hospital with chief complaints of pain in the abdomen since 45 days. History of present illness:- Patient was apparently asymptomatic 45 days  back, then he noticed pain in abdomen which is of dragging type which is in the epigastric region. Patient also complains of nausea and loss of appetite. No history of vomitings,constipation. Past history:-  Patient is not a known case of diabetes,  hyperte...
Read more