General medicine-04

Hello, I am P.Aishwarya ,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 portfolios

CASE SCENARIO:
CASE SHEET:
 A 65 year old women, resident of Cheruvgattu and she is housewife by occupation, presented  to the casuality with cheif complaints of weakness and drowsiness from past 4 days.
CHIEF COMPLAINTS:
Case of fever associated with fever and chills and rigors since 1week and high grade fever.
Difficulty in walking since 3days
Bilateral lowerlimb weakness  from 3days
Patient was apparently asymptomatic 10years back .
Loss of appetite .

 HISTORY OF PRESENT ILLNESS: 
Since 1 week she is having high grade fever associated with chills and rigors and decreased food intake  and missed OHA's since 2days
Difficulty in walking bilateral lowerlimb weakness.
Passage of urine and stool in clothes due to weakness in both the lower limbs

PAST HISTORY:
Patient is having diabetes mellitus since 10years and OHA'S.
It's a known case of hyperthyroidism since 20years

TREATMENT HISTORY:
For Diabetes Mellitus since 10 Years (OHA's) 

PERSONAL HISTORY:

-Decreased apitite
-Regular bowels
-Normal micturition
-no known allergies

FAMILY HISTORY:

-No hypertension
-No diabetes
-No heart disease
-No cancers 
-No asthma

GENERAL EXAMINATION:
No pallo3
No Icterus 
No Cyanosis 
No lymphadenopathy
Temperature:98.6
Pulse rate : 82 per minute 
Respiratory rate : 16/min
B.p : 120 / 80 
Spo :98%
GRBS:102

MENSTRUAL HISTORY:
Menopause 

SYSTEMIC HISTORY:

CVS
NO thrills
S1 ,S2 present
No cardiac murmurs
RESPIRATORY SYSTEM:
NO dyspenoea
No wheezing
Central position of trachea

ABDOMEN:
 Abdomen-scaphoid
No tenderness
No palpable mass
No hernial orifices
No bruits
No free fluids
Bowel sounds heard
No palpable liver and spleen

CNS:
Patient is  conscious Alert
speech: normal 
No neck stiffness

BIOCHEMICAL INVESTIGATIONS:
2D ECHO:
ECG:




PROVISIONAL DIAGNOSIS:
Diabetic keto acidosis.

Popular posts from this blog

GM -11

Image
 78 year female with diminution of vision, right hand pain,fever,tinnitus September 26, 2023 Hi, I am P.Aishwarya, 5th sem medical student. 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 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 a diagnosis and treatment plan.   CONSENT AND DE-IDENTIFICATION :  The patient and t...
Read more

GM-08

Image
Hi , I am P.Aishwarya ,5th 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 portfolios September 12, 2023 Hi, I am P.Aishwarya, 5th Sem Medical Student.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 is welcome.” I have 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, ...
Read more

GM -case 10

Image
Hi , I am P.Aishwarya ,5th 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 portfolios 55 F fever with since 10 days September 25, 2023 A 55 yr F came to OPD with C/C: fever since 10 days HOPI: the patient was apparently asymptomatic 10 days ago then she developed fever which was incidious in onset and gradually progressive, there are no aggrevating factors, relieved on taking medication  Past history: H/o taking medication - dolo 650( thrice a day) - taxim( twice a day) N/k/c/o DM, hypertension, asthama, TB, thyroid, epilepsy, CAD and CVA Family history: insignificant Personal history:  Sleep- adequate Appetite -reduced Diet- mixed Bowel and bladder - normal and regular Addictions- No addictions General examination:  C/c/c Moderately built and nourished No signs of pallor,iceterus, cyanosis, clubbing, lymphadenopathy and pedal edema no pallor  no icterus...
Read more