Gm case ( 76 yrs female)

 GENERAL MEDICINE 


23-11-22

This is an online E log book to discuss our patient's de-identified health data shared after taking his /her/guradian's consent.
This E log book also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box below.

DATE OF ADMISSION: 22-11-22

A 76 year old female housewife from narketpally came to opd with

CHIEF COMPLAINTS OF:
. Difficulty in breathing 
. Rashes on abdomen 

HOPI: 
. The patient was apparently asymptomatic 1 year back and and developed shortness of breath ( grade 3) which used to subside once she sits . Aggrevating factors- cold environment,  relieving factors- medications.
. Not associated with orthopnea and paroxysmal nocturnal dyspnoea 
. Around 10 days back patient developed multiple lesions on the left flank of abdomen,  sudden in onset , progressed to hyperpigmented Macules with crusting, no aggrevating or relieving factors , complaints of left iliac fossa pain radiating  to left hypochondrium since 5 days
. No h/o fever, burning micturition, chest pain , and decreased urine output 

PAST ILLNESS: 
. Known case of HTN from 25 years ( stopped taking medication 4 months back as her blood pressure was under control)
. Not k/c/o diabetes, TB , epilepsy,  CAD, CVA
. Known case of Asthma since 1 year

PERSONAL HISTORY:
diet- mixed
Appetite- decreased appetite since 4-5  months
Sleep- normal 
Bowel and bladder movements- regular 


SURGICAL HISTORY 
. No surgical history 


FAMILY HISTORY 
.No significant Family history 

.no known allergic history


PHYSICAL EXAMINATION 

General examination: 
. The patient is conscious,  coherent, cooperative 
. Well nourished and Moderately built 
. Mild pallor,  no icterus, cyanosis, clubbing, lymphadenopathy, Pedal edema 

VITAL SIGNS: on day of admission 

Pulse rate - 84 bpm

Respiratory rate - 18 cpm

Blood pressure - 130/80 mmHg

Temperature - afebrile 

GRBS - 114mg%


SYSTEMIC EXAMINATION :

CVS : S1 and S2 heart sounds hear

NO murmurs 

RESPIRATORY SYSTEM : Bilateral air entry present             

position of trachea - central 

Vesicular breathsounds heard

Dyspnoea grade 3 , wheeze present 

CNS : 

▪︎NAD and HMF intact

PER ABDOMEN 

Inspection- Umbilicus is central and inverted 

•No engorged veins, scars seen 


Palpation- all inspectory findings are normal 
. Tenderness felt in left lumbar, sacral and umbilical region 

Percussion: 
•No free fluid 

CLINICAL IMAGES:








PROVISIONAL DIAGNOSIS:
Chronic  bronchial asthma
Herpes zoster 
Sideward head nodding 


INVESTIGATIONS:

Hemogram
 

Blood sugar random



 
RFT



Liver function test



 ECG


USG Abdomen
 

2D ECHO



TREATMENT:
. Nebulizer salbutamol 2 respules
. Tab pantop 40mg po/od
. Tab ultracet  po/ qid
. Amoxyclav 625mg po/tid
. Tetrabenazine 12.5mg po/od

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