Final year general medicine short case presentaion

Bhavani vegesena

Roll no 141

Friday, June 10,2022

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 comments 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 DEIDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

CASE:

A 46 years old female who is an agriculture laborer by occupation came with the chief complaints of:

• Shortness of breath since 1week
• Abdominal distention since  1 week

History of presenting illness:

The patient was apparently asymptomatic 1 year back when she developed dyspepsia for which she was started on medication on and off and was fine.

The patient then developed shortness of breath on exertion since 1 week which was not associated with chest pain, palpitations, pedal edema, or cough.

The patient also noticed a swelling in the epigastric region on exertion and then developed abdominal distention a week back.

No history of cough, fever or cold.

History of past illness:

No similar complaints are seen in the past.

Not a known case of hypertension, diabetes , TB, epilepsy or asthma.

FAMILY HISTORY :

No history of similar complaints in the family 

PERSONAL HISTORY : 

Appetite : Normal 

Diet : Mixed

Sleep : Adequate

Bowel and bladder movements : Normal 

No addictions and no drug allergies

Daily routine:

GENERAL EXAMINATION : 

Patient is conscious , coherent and cooperative, moderately built and nourished and well oriented to time , place and person. 

Pallor - Absent

Icterus - Absent 

Clubbing - Absent

Cyanosis - Absent

Lymphadenopathy - Absent

Edema - Absent 

Systemic examination:

Cardiovascular system:

1. Heart sounds: S1 and S2 heard
2. No cardiac murmurs heard
3. No thrills 

Respiratory system:

1. Shape of chest is elliptical, b/l symmetrical.
2. Trachea is central.
3.  Expansion of chest is symmetrical.
4. Bilateral Airway E - positive

Per abdomen:

INSPECTION:

Shape – distented

Umbilicus –central in position , inverted.

All quadrants of abdomen are moving equally with respiration.

Cough impulse positive: swelling seen on coughing

No visible pulsations or scars

PALPATION:

No local rise of temperature and tenderness

All inspectory findings are confirmed.

Swelling is noted in the epigastric region.

Deep palpation- no organomegaly.

AUSCULTATION:

Bowel sounds are heard.

CENTRAL NERVOUS SYSTEM : 

No focal neurological deficits

Sensory and motor systems intact 

Normal power , tone and reflexes 

INVESTIGATIONS : 

Complete blood picture:

10/06/22:

11/06/22:

Complete urine examination:

Liver function tests:

Blood sugar- random: 332 mg/dl

GRBS CHARTING: 11/6/22
8PM: 282 mg/dl

10PM: 310 mg/dl

12AM: 390 mg/dl

12/6/22
6AM: 257 mg/dl

2PM: 128mg/dl

Serum electrolytes:

Sodium: 138mEq/L

Potassium: 3.3mEq/L

Chloride: 99mEq/L

Electrocardiogram:

Colour doppler 2D echo:

1. Sclerotic Aortic Valve
2. Good LV systolic function
3. Mild diastolic dysfunction (mild TR)

No intracardiac masses

Ultrasound:

1. 15mm defect noted in the Epigastrium with herniated contents( Omentum included)
2. Grade 2 fatty liver

Provisional diagnosis:

46 year old female with abdominal distension, denovo type 2 Diabetes Mellitus.

Treatment:

1. INJ NPH: 4U AT 8AM AND 4U AND 8PM
2. INJ HAI: 6U AT 8AM, 6U AT 2PM, 6U AT 8PM
3. INJ PANTOPRAZOLE 40MG IV OD
4. TAB ULTRACET [ ACETAMINOPHEN+TRAMADOL PO (1/2 TABLET) SOS]
5. INJ OPTINEURON( B COMPLEX) IN 100ML NS IV OD