70 Y/O MALE WITH SOB, COUGH, FEVER

A 70 year old male, resident of Nalgonda, coal miner by occupation cane with the chief complaints of:

1. Fever since 15 days

2. Shortness of breath since 10 days

3. Cough since 10 days

HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic 15 days back when he developed a fever, sudden in onset, intermittent with a rise in temperature at night, associated with chills and rigors. No aggravating factors were noted, relieved on taking Tab. Paracetamol.

He noted a history of Shortness of Breath since 10 days, insidious in onset, Grade III (NYHA classification) with was aggravated on working and relieved on rest. There was no associated diurnal or positional variation, or paroxysmal nocturnal dyspnoea.

He also had a history of cough since 10 days, associated with copious amounts of whitish sputum, non-foulsmelling and non-bloodtinged.

He had no history of chest pain.

PAST HISTORY

One episode of dull-aching chest pain with palpitations 10 years back, for which angiogram was performed. He has been taking statins since then.

History of HTN since 5 years, for which he takes amlogen (CCB) regularly.

History of Type2 DM since 2 years, for which he takes glimepiride.

History of asthma- since 2 years, for which he has been using an inhaler.

No history of TB, epilepsy, thyroid dysfunction.

PERSONAL HISTORY

Diet: Mixed

Appetite: normal

Sleep: decreased

Bowel and bladder movements: regular

Addictions: Smoking since 50 years, stopped since 2 years. Takes alcohol everyday since 40 years, between 50-100ml.

No known food or drug allergies

FAMILY HISTORY

Insignificant

GENERAL EXAMINATION

Patient conscious, coherent, cooperative

Well oriented to time, person, place

Moderately built, well nourished

No pallor, icterus, cyanosis, clubbing, lymphadenopathy

B/L pedal edema- uptil knee

Vitals:

PR- 112bpm

BP- 140/80mmHg

RR- 20cpm

SpO2- 98% at room atm

SYSTEMIC EXAMINATION

CVS: S1, S2 heard

PA: Soft, nontender

CNS: no abnormalities found

RS: BAE+, with expiratory wheeze present in supra, inter, Infrascapular areas bilaterally

PROVISIONAL DIAGNOSIS

Viral pyrexia with chronic bronchial asthma with lung pathology under evaluation

Diagnosis: Viral Pyrexia with Pneumoconiosis (occupational lung disease)

TREATMENT

1. O2 supplementation

2. Nebulisation with duolin 6hrly, Budecort 8hrly

3. Inj Pan 40mg IV OD

4. Syrup Ascoryl TID

5. Tab Prednisolone 5mg OD

6. Inj Monocef 1gm IV BD

7. Tab Azithromycin 500mg OD

8. Tab dolo 650mg BD

9. I/O monitoring

Comments

50 YEAR OLD FEMALE WITH FEVER, LEFT LOIN PAIN

This is an online E-log entry blog to discuss and understand the clinical data analysis of a patient, to develop competency in comprehending clinical problems, and providing evidence- based inputs in order to come up with a diagnosis and effective treatment plan to the best of my ability. Mentioned here are my learning points, both theoretical and practical surrounding this patient: -Taking psychosocial and past history of this patient was particularly eye opening. She had several hospital admissions in the last 2 years with 3 for pyelonephritis alone. Her history made me realize the hardships of patients with chronic health conditions, and the pain that both her and her family would have to suffer from it. -I also got to learn the pathophysiology of PAH and how to causes murmurs. Additionally, I got to appreciate the murmurs in this patient as well. -An interesting medical dilemma surrounding this patient was whether or not to give IV fluids. 2D ECHO showed a collapsing IVC along w

22 OLD FEMALE WITH INTERMITTENT FEVERS SINCE 1 YEAR, URINARY INCONTINENCE SINCE 1 DAY

This is an online E-log entry blog to discuss and understand the clinical data analysis of a patient, to develop competency in comprehending clinical problems, and providing evidence- based inputs in order to come up with a diagnosis and effective treatment plan to the best of my ability. Mentioned here are my learning points, both theoretical and practical surrounding this patient: -I performed a full sensory and motor system examination on this patient and recorded my findings below. Additionally, I learnt how to localize the level of spinal cord lesion based on my findings. Beaver's sign was a learning point for me as well. -Learnt how to differentiate LMN bladder from UMN type bladder -Learnt about NMOSD (Neuromyelitis Optica Spectrum Disorder), its symptoms and possible clinical findings The patient came to the OPD with chief complaints of: -Urinary retention since 1 day HISTORY OF PRESENTING ILLNESS: Patient was apparently asymptomatic 1 year back when she developed headac

55 YEAR OLD MALE WITH TINGLING IN ALL LIMBS

This is an online E-log entry blog to discuss and understand the clinical data analysis of a patient, to develop competency in comprehending clinical problems, and providing evidence- based inputs in order to come up with a diagnosis and effective treatment plan to the best of my ability. Mentioned here are some learning points that I found interesting, both theoretical and practical surrounding this patient: -Performed multiple Ryle's tube insertions in this patient -Learnt how to calculate eGFR, and determine type of AKI in this patient A 55 year old male presented to the casualty with chief complaints of: Tingling and numbness in all limbs since 3 days One episode of altered sensorium History of Presenting Illness: The patient initially started drinking 15 years ago when he was 40, due to peer pressure as all his friends in farming would drink too. Once his son met with an accident and broke his arm 6 years ago, the patient's drinking increased. Started drinking heavily 10

Vibha Hegde

Search This Blog