Vinila Bhavani .K General medicine answer sheet

















 

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CHIEF COMPLAINTS: A 54yrs old female who is a housewife from Nalgonda came to opd with chief complaints of SOB since 2days and generalised weakness. HOPI: Patient was apparently asymptomatic  8 months ago then she developed SOB which is insidious in onset and continuous in nature which aggravates on walking and also on lying down.It gets relieved on sitting position [grade 3 SOB].It is also associated with dry cough.She also has genearalised weakness and also fever since 8months which is intermittent in nature. She consulted a local doctor in Nalgonda from where she got to know that she has low Hb levels for which she underwent blood transfusion and again back in July her Hb levels were found low[5.0g/dl] and again she underwent blood transfusion[2units] after which her Hb levels increased from 5.0 -8.0g/dl.She again developed SOB and generalised weakness since 2days for which she again consulted a local doctor in Nalgonda and got her tests done. ...
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This is K.Vinila Bhavani , 8 th sem student .This Elog depicts patient centred approach to learning. This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.This E blog 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, clinical findings, investigations and come up with diagnosis and treatment plan.

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A 40 yr old male patient , resident of mirualguda , who is daily wage labourer by occupation came to OPD with chieft complaints of pain abdomen since 5 days associated with fever since 2 days . History of present illness  Patient was apparently asymptomatic 5 days ago then he developed pain which is insidious in onset and gradually progressive which is diffuse , squeezing type and radiating to back .Pain is relieved on medication . No C/O of vomitings , loose stools , burning micturition ,cough,cold , chest pain , SOB . History of past illness N/K/C/O  TB , hypertension, diabetes, Asthma, epilepsy , CAD, thyroid disorders . Personal history  Diet - mixed  Appetite- normal Bowel and bladder -regular Sleep - adequate Addictions - regular alcohol intake of 250 ml per day since 20 yrs . No food allergies and drug allergies Family history  Not significant General examination Pallor - yes  Edema - no  Clubbing - no  Lymphadenopathy - no  Icterus - ...
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K Vinila Bhavani

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 65 yr old female patient , who is a daily wage labourer came to casualty in altered state  with complaints of : Episodes of slurring of speech since 1 day  Profuse sweating that resolved on having food. Patient was asymptomatic till yesterday 4 pm . patient was brought to casualty in uncounsious state   HISTORY OF PRESENT ILLNESS : Patient has no involuntary movements . Patient has history of sweating and snoring . HISTORY OF PAST ILLNESS : In 2014 patient was discovered with GIST - gastrointestinal stromal tumour on histopathological examination.  In 2016 patient was found to be Mets+ve and was treated with anticancer drugs . In 2019 he was again found to have Mets 16mm in liver . Eye movements1, verbal1, motor4  PERSONAL HISTORY : Diet - mixed  Apetite - normal Bowel movements - regular  Micturition - normal Patient use to drink alcohol occasionally . THERE IS NO RELEVANT FAMILY HISTORY . Patient was having diabetes . VITALS  Pallor - yes...
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