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General medicine case 


 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  34 year old male who works at printing shop came to the OPD with the chief complaint of abdominal pain since 1 years which got aggravated since 1 month. He also complaints of loss of appetite since 20 days & complaints of 1 episode of blood tinged vomitings  20 days back. 

 History of present illness : 

Normal routine of the patient : 

The patient wakes up by 4AM daily, as soon as he wakes he consumes alcohol,then he sleeps for sometime & there is no specific time for his breakfast,lunch and dinner.  Since 2 months he has been experiencing generalized weakness, so much so that he stopped going to work. 

The patient was apparently asymptomatic 15 back, then he started consuming whiskey 90ml 2 to 3 times per week and gradually increased to 360 ml / day  in 15 yrs. Patient experiences sleep disturbance, tremors, when not consuming alcohol. 


History of past illness:

Patinet is not a known case of Diabetesmellitus, hypertension,asthma , tuberculosis,jaundice , epilepsy.

Family history: 

No similar complications seen in family members.

Drug history : 

patinet is not allergic to known drugs

Personal history: 

Diet : mixed

Appetite: lost

Sleep: adequate

Bowel and bladder movements ; constipation

Micturation: normal

Habits: alcoholic , occasionally smoking.

Allergies : no known allergies


General physical examination:

Patinet is pallor 





No cyanosis

No icterus 

Malnourished

No clubbing of fingers

No lymphadenopathy

No edema of feet 

Vitals : 

Temperature: 98°F

Pulse rate : 84 bpm

Respiration rate : 18 cycle 

Respiration rate : 18 cycle per min


Bllod pressure :120/89 mm hg


GRBS 102 mg 


Spo2 99%


Systemic examination:


Cardiovascular system:


S1 and S2 heard 


No murmurs heard




Respiratory system:


Location of trachea central


No wheezing sounds


Breathing sounds vesicular.


Abdomen:


Shape of abdomen : scaphoid 


Abdominal tenderness grade 1 pain


No palpable masses


Hernial orifice is normal


Bowel sounds heard




Level of consciousness:


Patient is conscious, coherent,and cooperative to time and place.


Speech is normal


Motor , sensory system noramal


All reflexes are normal.


Provisional Diagnosis: chronic pancreatitis.


Investigations:


Investigations:



















General medicine case 1

August 10, 2021


Image
  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. A 48 year old male patient presented to the OPD with the chief complaint of fever and swelling in the right lower limb since 4 days. History of present illness : - Patient was apparently asymptomatic 4 days back then he noticed a swelling on the right lower leg due to trauma.  - The swelling is associated with pain, no discharge, no sinuses.  - It is associated with low grade fever and is intermittent.  - Fever is not associated with chills and rigors. History of past illness :  - There is no history of diabetes, hypertension, asthma, tuberculosis, epilepsy - There is no history of surgery - The p
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General medicine case 2

August 23, 2021
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  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.  Date of admission : 16th August 2021 A 70 year old male presented to the OPD with the chief complaint of fever, low urine output, back ache and shortness of breath since 10 days. History of present illness : - Patient was apparently asymptomatic 4 years back then he developed shortness of breath, pedal edema for which he was admitted to hospital. - He was treated for the above condition. - 3 years back he developed back pain which was intermittent and was on medication - since 2 months he had fever, back pain - since 1 month he developed shortness of breath and pedal edema History of past illness :  - He
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General medicine case 4

September 27, 2021
Image
  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 60 year old female who is daily wage labourer by occupation came with the chief complaint of 1. Lower back pain  2. Facial puffiness 3. Pedal edema History of present illness : - Patient was apparently asymptomatic 4 months back then she developed fever and backache for which she was treated symptomatically. She used to take analgesics for a temporary relief from the backache. - Later when the conditions repeated again, she was taken to a local hospital where she was diagnosed with kidney failure. - She is currently undergoing dialysis twice a week. History of past illness :  - The patient is a known cas
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