Dr Bhavya

 

24Y/M WITH SOB

 This is an a 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.


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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 diagnosis and treatment plan

A 24 year old male daily wage labourer came to the OPD with a chief complaints of decreased urine output, shortness of breath and vomitings since 4 days. 

HOPI

Patient was apparently asymptomatic 8 days back then he developed severe vomitings due to an excessive binge drinking without any consumption of food. The vomitings were non bilious, non blood stained, non foul smelling, watery and occurred immediately after consumption of food or liquids. 
Patient developed oral ulcerations later that day. He was taken to a local hospital where medication was provided. 4 days ago he had complaints of shortness of breath (Grade 4)  and decreased urine output with blood in the urine. On taking him to a local hospital, dialysis was advised after which he was admitted to our hospital. 2 days ago the patient was observed to develop a white coating in the mouth and over the tongue( dermatology opinion taken).  
  

He has no H/o fever, loose stools, pedal oedema, burning micturition, cough 

Past history:
No similar complaints in the past
No H/o HTN, diabetes, asthma, epilepsy and tuberculosis. 

Personal history:
Diet: mixed.             Appetite: decreased 
Bowel and bladder: irregular.      
Sleep: adequate.       Addictions: alcohol and paan. 
Allergies: none.          ( binge drinking episode. Daily      
                                     80ml. )
Family history: not significant 

General examination:
Patient is conscious coherent and cooperative moderately built and nourished

Vitals
Temperature: afebrile.            PR: 83bpm
RR: 22cpm.                            BP: 140/90mmHg

Pallor: absent 
Icterus: present


Cyanosis: absent
Clubbing: absent 
Lymphadenopathy: absent
Oedema : absent

Systemic examination:

Per abdomen: soft on palpation, bowel sounds heard,    no distention present




Respiratory system: no wheeze heard, no crepitus heard, normal vesicular breath sounds heard

CVS: S1 S2 heard, no additional murmurs

CNS: no focal neurological deficits
Investigations:




ECG


USG


Chest Xray

Provisional diagnosis: Alcohol liver disease ,Acute  kidney injury, oral candidiasis. 

Treatment:
- IV NS
- Inj zofer (SOS)
-Inj Doxycycline 100mg BD
- Inj Thiamine 200mg in 100ml NS TID
- Inj Monolef BD
- Inj Lasix 40mg BD




Popular posts from this blog

Dr Bhavya

Image
13 YEAR OLD WITH GROSS HAEMATURIA AND ANASARCA 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 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 inputs on the 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. 13Y/F presented to the opd with chief complaints of  1) fever since 36 days 2) red coloured urine since 33 days  3) pedal edema since 30 days
Read more

Dr Bhavya

75 year old male with SOB. 75 year old male resident of Suryapet came to OPD with chief complaints of cough since 2 months and breathlessness since 1 month and Pedal edema since 15 days. History of presenting illness. Patient was apparently asymptomatic 2 years ago ,later he developed SOB,pedal edema and generalised weakness for 2 weeks and for which he was treated. 2 months ago he developed cough with sputum , which is white in color, not blood stained and non foul smelling. And also SOB which gradually progressed from Grade 3 to Grade 4 ,one month ago. He also developed facial puffiness 20 days back . Along with pedal edema with is of pitting type.He has chest pain since 10 days which aggrevated with SOB. No H/O fever with rash,hemoptysis,nausea,vomiting,constipation. Past history: Not a k/c/o HTN,DM,Thyroid,asthma,epilepsy,Congenital heart Disease.  Personal history: Diet-mixed Appetite-normal Bowel and bladder movements-Regular Sleep -adequate Addictions-chronic smoker since 30 yrs
Read more

Dr Bhavya

Image
80year old with fever ,burning micturition and dysphagia 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 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 inputs on the 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 80 year old female presented with the complains of fever since 3 months, burning micturition since 3 months, difficulty in swallowing
Read more