🍁Greetings to one and all going through my E log!!
🩺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.
I am Nomika Alli (Roll no 179) of 8th Sem MBBS.
A 80 yr old male came to OPD on 11th Aug 2023 with c/o Shortness of breath since 1yr and c/o epigastric pain & discomfort after eating food since 6 months.
HISTORY OF PRESENT ILLNESS:
Patient is apparently asymptomatic 1 yr back and then developed Shortness of breath which is insidious in onset, gradually progressive , progressed from grade I to grade II.
No PND, No orthopnea, no diurnal and seasonal variations.
Epigastric pain and discomfort after eating food since 6 months (more after eating spicy foods).
No H/O Chest pain, palpitations, pedal edema, giddiness.
No H/O vomiting, cough, loose stools, vomiting
H/O Bilateral knee pains since 2 yrs
N/H/O trauma, fall
HISTORY OF PAST ILLNESS:
N/K/C/O DM, HTN, TB, Asthma, CAD, CVD, Epilepsy
NO H/O similar complaints in the past
NO SURGICAL HISTORY
FAMILY HISTORY:
N/K/C/O DM, HTN, TB, Asthma, Epilepsy, CAD, CVD
PERSONAL HISTORY:
Diet: Mixed
Appetite: Normal
Sleep: adequate
Bowel and bladder movements: Regular
Addictions: Alcohol once in a month (quarter)
Allergies: no known
GENERAL EXAMINATION:
Patient is conscious, coherent, cooperative to time, place and person.
Ht: 160 cm Wt: 70kg
No signs of pallor,
no icterus,
no clubbing,
no cyanosis,
no koilonychia,
no lymphadenopathy,
no edema
vitals: temp: 96 °F
BP: 190/100 mmHg
HR: 98 bpm
RR: 18cpm
SpO2: 98%
GRBS: 148mg%
SYSTEMIC EXAMINATION:
CVS:
S1 S2 present
No thrills
No murmurs
Respiratory system:
Normal Vesicular breath sounds +
Position of trachea is central
No dyspnoea
No wheeze
Abdomen:
Shape of abdomen: scaphoid
No tenderness
normal hernial orifices
No palpable masses
No free fluids
liver and Spleen: not palpable
no bruits
bowel sounds heard
CNS:
Patient is conscious
Normal speech
No neck stiffness
kernig's sign negative
Glasgow scale 15/15 [E4 V5 M6]
Reflexes normal
cranial nerves normal intact
motor and sensory normal intact
No cerebellar signs
PROVISIONAL DIAGNOSIS:
APD
Acid Peptic Disease
MANAGEMENT:
1)T. Pantop 40mg 8am
2) T. Nicardia 10mg 8am
3) T. Ultracet 3x /day 8am---2pm---8pm
4)T. Shelcal 500mg 2pm
.png)
.png)
No comments:
Post a Comment