A 26year old Patient came to casuality with shortness of breath

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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.

A 26 year old male patient, resident of adauidulpally, Nalgonda district farmer by occupation came to our hospital with chief complaints of -

1. Shortness of breath
2. Loss of appetite
3. Low grade Fever 
4. Pedel edema

Date of admission :- 05/04/2022

History of present illness:-
Patient was apparently normal 1week back , then he had one episode of low grade fever, Generalized body pains, burning micturtion but relieved with medication.Then developed pedal edema,initially till ankle
Loss of appetite 
4-5 days back associated with nausea and 
4 days back one episode of vomiting 
Non bilious and no food particles 
No H/o of constipation, No H/o chronic cough present, No H/o of trauma

History of past illness:-
 H/o Rat bite 5 months back 
Not a known case of diabetes, hypertension, tb, epilepsy, asthma 

Personal history:-
Patient has normal eating habit with mixed diet.
Regular alchohol consumption and no smoking.

Daily routine:-
Patient used to wake up at 7.00AM , takes breakfast at 9.00AM .Then he goes to her  work and takes rice in between 4.00PM-5.00PM and dinner at 10.00PM and goes to bed by 11.00PM.

Family history:-
No significant family history.

General examination:-
Patient is conscious, coherent, cooperative and well oriented to time, place and person
No Pallor 
Icterus present
No clubbing
No lymphadenopathy

Vitals:-
Temperature-afebrile
Pulse rate- 90 bpm
RR-24 /min
BP-100/60mmhg
SPO2-97% at room air
ECG
2D ECHO
ULTRA SOUND 
TPR 

Investigations:-
ECG
Ultra sound scan of abdomen
Colour doppler 2D echo

Provisional diagnosis:-
AKI
ALI

Treatment-
 IV fluids 175ml/ her
TAB doxycycline 100mg PO/BD
Inj PAN 40 mg IV/OD
Inj optineuron 1 amp in 100ml NS /IV/OD
TAB PCM 650 mg PO 





Comments

Post a Comment

Popular posts from this blog

A 65years old male came to opd with chief complaint of bilateral pedal edema and Shortness of breath

Image
A 65 yr old male patient with swelling on the both the legs and difficulty in breathing ( short case) January 20,2023 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. CHIEF COMPLAIN: A 65years old male resident of nagarjuna sagar came to opd with chief complaint of bilateral pedal edema and Shortness of breath History of Present Illness : -Patient was apparently asymptomatic 10years back, then he met with an accident fell while riding bullock cart injuring his mandible) . Then he started using NSAIDS following 8 years back  develo
Read more

A 55yr old female came to hospital with the complaint of breathlessness

Image
A 55yr old female complains of fever,decreased appetite since 1 month, Breathlessness since 1 week,vomitings and loose stools since 3 days. October 27, 2022 CHIEF COMPLAINTS: Pt complains of fever,decreased appetite since 1 month, Breathlessness since 1 week,vomitings and loose stools since 3 days.  History of present illness : Patient was apparently asymptomatic 3 months back. Then she had multiple swellings in front of the left ear, for which she developed fever which was lowgrade, intermittent, no evening rise of temp, ass with decreased appetite since 1 month. She then had vomitings which was non bilious and non projectile, containing food particles. She had history of loose stools since 3 days, which is 4-5 episodes per day, watery in consistency.  Past history: K/c/o Hypertension since 7 years.  7 yrs back she had c/o giddiness for which she went to hospital and was found to have HTN.  Personal history: Diet- mixed Appetite-decreased Bowel and Bladder movements- regular. Addicti
Read more

A 45 years male patient came to casauality with the complains of Abdominal pain and pedal edema

Image
45/M with Abdominal distension and pedal edema This is 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 patients 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 . 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 diagnosis and treatment plan. Case:  45 year old male complaints of abdominal distension and b/l pedal edema (pitting type) , shortness of breath and scrotal swelling  Chief complaints Patient compla
Read more