General Medicine E log 3

July 18, 2022


A 65 YEAR OLD FEMALE PATIENT CAME WITH DRYNESS OF MOUTH AND ABDOMINAL PAIN

Hi, I am Humera Firdous of 3rd semester .This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio.

The patient’s consent was taken verbally prior to history taking and examination of her condition.

CASE SHEET:

Chief complaints:

A 65 year old female , home maker by occupation, hailing from chityal, came to casualty on 16 th of July , with chief complaints of :
- fever since 3 days
- abdominal pain since 3 days
- vomitings in the morning
- Shortness of breath 

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic 3 days ago. The patient was a known case of type 2 diabetes since 10 years. The patient was on medication everyday with insulin injection by patient's husband.

The patient has a history of shortness of breath since 4 months.The patient developed fever dove 3 days, which was intermittent, not associated with chills and rigors. The fever subsided on medication with paracetamol.

The patient has decreased appetite and food intake. She also had vomitings(4 episodes) , undigested food as content of vomit , which was relieved on prescription of a physician.

Then the patient gave complaints of pain in the abdomin above umbilical region. It was not associated with food pattern.

ASSOCIATED DISEASES:

The patient is a known case of type II Diabetes Mellitus for 10 years. 

PAST HISTORY:

The patient has a history of coronary artery disease.

PERSONAL HISTORY:

Diet: Mixed
Bowel: Regular
Micturition: Normal
Appetite: Normal
Habits: no addictions
No history of allergy, hypertension, asthama, tuberculosis, epilepsy.

FAMILY HISTORY:

No family history

DRUG HISTORY:

INJ- MIXTARD for diabetes
Tablets- ECOSPRIN 75

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative
No pallor
No icterus
No cyanosis
No lymphadenopathy
No clubbing
No pedal edema
No malnutrition
Mild dehydration

VITALS:

Temperature: 98.6 F

Pulse: 96 beats per minute

Respiratory rate: 21 cycles per minute

SPO2: 96%

GRBS: High

SYSTEMIC EXAMINATION:

Cardiovascular System:

No thrills
Cardiac sounds: SQ and S2 heard
No murumurs

Respiratory system:

Vesicular breath sounds heard
Mild dyspnea
No wheezing

Abdomen:

Shape of abdomen: scaphoid
Tenderness: present-epigastric region
No palpable mass
No bruits
Non palpable liver
Non palpable spleen
Bowel sounds: heard

CENTRAL NERVOUS SYSTEM:

Conscious
Speech-normal

INVESTIGATION:

Complete blood picture



PROVISIONAL DIAGNOSIS:
Diabetic ketoacidosis
 


Comments

Post a Comment

Popular posts from this blog

General Medicine E log 7

January 3,2023 A 35 year old female with complaints of painful lesions on her body,fever,burning sensation on the lips, difficulty in swallowing since the past 1 week. Hi, I am Humera Firdous of 3rd semester .This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio. The patient’s consent was taken verbally prior to history taking and examination of her condition. CHIEF COMPLAINT: A 35 year old female patient who works on a farm land and is a resident of Nakrekal district came to the OPD with complaints of painful lesions on the neck, chest and leg associated with fever since the past 1 week. HISTORY OF PRESENT ILLNESS: The patient was apparently asymptomatic 1 week ago.Then she developed painful lesions on the neck,chest,arms and legs which was associated with fever The fever was insidious in onset.More during the day time.The fever was gradually reduc
Read more

General Medicine E blog-2

Image
July 27 2022 A 21 year old female patient with fever, vomiting and generalised body pains Hi, I am Humera Firdous of 3rd semester .This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio. The patient’s consent was taken verbally prior to history taking and examination of her condition. CHIEF COMPLAINT: A 21 year old female patient who is a student came to the casualty on 22nd of July with complaints of high fever, vomitings and generalised body pains. HISTORY OF PRESENT ILLNESS: The patient was apparently asymptomatic 8 days ago. Then she developed high fever on morning of 21st July associated with chills and generalised body aches.Later that evening she started vomiting (non-bilious) with food as content which was associated with abdominal pain.She had 6 episodes of vomiting that evening.Then  she presented to the casualty on 22nd of July where she w
Read more

General Medicine Blog 5

Image
            35 year old male with swelling , ulcer with pus discharge  on his right foot  since the past 10 days Hi , I am Humera Firdous  ,3rd semester student. This is an online elog book to discuss our patients health data after taking his consent. This also reflects my patient centered online learning portfolio.  CHIEF COMPLAINT-  A 35 year old male patient resident of choutuppal and driver by occupation presented to the department with chief complaints of fever along with pain and swelling with pus on the sole of the right foot near the second toe since 10 days.  HOPI - The patient was apparently asymptomatic 10 days ago. He developed fever which was continuous and along with it he also noticed a swelling on the plantar surface of right foot near his 2nd toe associated with pus.He also had pedal edema on right leg. He visited a RMP ten days ago and was prescribed medications which reduced his fever for a while but did not reduce the swelling. After 3 days he visited the department
Read more