General medicine case 6

I'm Maimuna Fathima,3rd year BDS August 14,2023

This is an E-log to discuss case scenario of a patient.
I have been given this case to solve in an attempt to understand topic of patient,clinical data analysis to develop my competency in reading and comprehending clinical data including history,clinical findings,investigation and come up with diagnosis and treatment plan.

A 36 year old male was brought to the OP because of Shortness of breath since 4 days, generalized swelling since 4 days and decreased urinary output since 4 days 

Chief complaint:
Shortness of breath since 4 days 
Generalized swelling since 4 days 
Decreased urinary output since 4 days 

History of present illness:
Patient was apparently asymptomatic 4 days ago then he developed grade 4 Shortness of breath which was insidious in onset and gradually progressive which was aggrevated on walking. Orthopnea is also seen 
Then he developed pitting type of Generalized swelling and decreased urinary output.
No passage of stools since 4 days.
History of fever 6 days back which was continuous and associated with chills.

History of past illness:
5 years back patient had an accident and fell from bridge for which he got treated.After getting operated he noticed numbness in his lower limbs then he got a prick on his right lower limb which lead to septic and thereby got his leg removed.
Epilepsy 15 years ago.
Not a known case of hypertension,Diabetes, TB,Asthma.

Personal history:
Diet:Mixed 
Appetite:Decreased 
Bowel and bladder:Irregular 
Sleep:Adequate 
Micturation:Decreased 
Allergies:None
Addictions:Chronic alcoholic,chronic smoker(1 pack per day)
History of consumption of chewable tobacco,stopped 15 years back 

Family history:Not significant.

General examintion:Patient is conscious,coherent and well oriented to time,place and person.
Pallor:No
Cyanosis:No
Icterus:No
Clubbing:Yes(Stage 3)
Edema:Yes(pitting type)
Lymphadenopathy:No

Systemic examination:

GIT:

Inspection:
Shape:Distended 
Skin:Scars present 
No dilated veins 
Umbilicus:central and inverted 
Equal symmetrical movements in all quadrants with respiration.
No visible pulsation,peristalsis 

Palpation:
No tenderness 
No local rise in temperature 
No palpable masses 
Spleen and liver are not palpable 

Percussion:
Fluid thrill Absent 
Shifting dullness:present 

Auscultation: 
Bowel sounds:reduced 3-4/min 


Respiratory system:
Inspection:
Upper Respiratory tract:
Haliotosis:Absent 
Oral hygiene:Decreased 
Discoloration of cervical 3rd of posterior teeth and maxillary anteriors 
Calculus present,Gingival recession is seen
Brownish Discoloration of buccal mucosa 
Dental caries:present 
Post nasal drip:Absent 
Tonsils:Normal
Normal Nasal septum 
Nasal polyp:Absent 
Sinus,tenderness:Absent 

Lower Respiratory tract:
Inspection:
Chest:Symmetrical 
Chest shape:elliptical 
Trachea: Midline 
Drooping of shoulders:Absent 
Supraclavicular,infraclavicular hallowing:Absent 
Pectus excavatum:Absent 
Pectus craniatum:Absent 
Dyspneoa:Present 

Palpation:
Trache:Normal,midline 
Chest:symmetrical 
Intercoastal indrawing:Absent 
Kyphoscoliosis:Absent 
Hemithorax:
Transverse:109 cm 
Anteroposterior:52 cm 

Auscultation:
Breath sounds:Vesicular 
Vocal resonance 
Crackles heard 

CVS:
Inspection:
Chest shape:elliptical 
Scars:Absent 
Sinuses:Absent 
Dilated veins:Absent 
Apical impulse:Not visible 
Dilated veins:Absent 
Trachea:central 
Parasternal impulse:Not visible 
Jugular notch pulsations:Not visible 
Pulsation in epigastric area:Not visible 

Palpation:
No rise of local temperature 
No tenderness 
No thrills 
No heaves 
Kyohoscoliosis:Absent 
Apical impulse:Normal 
Pedal edema:present,pitting type 

Auscultation:
S1,S2 heard 
No murmurs 

Provisional diagnosis:Pulmonary edema 

Popular posts from this blog

General medicine case 4

I'm Maimuna Fathima,3rd year BDS March 4th,2023 This is an E-log to discuss case scenario of a patient. I have been given this case to solve in an attempt to understand topic of patient,clinical data analysis to develop my competency in reading and comprehending clinical data including history,clinical findings,investigation and come up with diagnosis and treatment plan. A 70 years old male,farmer by occupation was brought to the OP because of Shortness of breath and swelling in limbs and face 9 days ago Chief complaint: Shortness of breath since 9 days  Swelling of limbs and face by 9 days  History of present illness: Patient was apparently asymptomatic 9 days back then he developed Shortness of breath and generalized swelling in hands,legs and face.He even started feeling difficulty in passing out urine. History of past illness: Hypertension since 8 years   No Diabetes  No TB Family history:Not significant  Personal history: Diet:Mixed  Appetite:Decreased  Bowel and bladder:Irreg
Read more

General Medicine

I'm Maimuna Fathima,3rd year BDS student  February 28,2023 This is an E-log to discuss case scenario of a patient. I have been given this case to solve in an attempt to understand topic of patient,clinical data analysis to develop my competency in reading and comprehending clinical data including history,clinical findings,investigation and come up with diagnosis and treatment plan. A 60 year old female was resident of Nalgonda came to OPD on 26th feb 2023,with chief complaint of  -Decreased urine output  -Pain in lower Abdomen  History of present illness: Patient of apparently asymptomatic 5 years ago then she started feeling difficulty in passing out urine and started experiencing Shortness of breath.She also started feeling pain in the lower Abdomen from past 3 days. Past history: Hypertension since 4 years  Diabetes since 7 years  Family history:Not significant  Personal history: Diet:Vegetarian  Appetite:Decreased  Bowel and bladder:Not regular  Sleep:Inadequate  Addictions:Non
Read more

General Medicine

I'm Maimuna Fathima,3rd year BDS student  February 13,2023 This is an E-log to discuss case scenario of a patient with their guardian's help. I have been given this case to solve in an attempt to understand topic of patient,clinical data analysis to develop my competency in reading and comprehending clinical data including history,clinical findings,investigation and come up with diagnosis and treatment plan. A 68 year old female resident of West Bengal came to OPD on 2nd Feb 2023,with chief complaint of  -Shortness of breath since 7 months  -Cough(productive) since 7 months  History of present illness: Patient was apparently asymptomatic 7 months ago then she developed difficulty in breathing which aggrevated on walking and relieved on rest with no postural variation. She developed cough which was productive, white in colour and thick in consistency,more at night. Past history:Not a known case of hypertension,Diabetes,asthma,TB,epilepsy  Family history:Not significant. Personal
Read more