medicine log book

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June 26,2020

Hello everyone...  I am sivani an intern in the medicine department and of the important  terms of getting the internship completion is to complete my log book with my online log of what i have learnt during my clinical course.

       "This is an online e log book to discuss our patients deindentified health data sharing after his/ hers guardians signed informed consent.

          Here we discuss our indi6vidual patients problems through a series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current evidence based inputs.

            This elog also reflects my patient centered online learning portfolio and your valuable inputs on the comments box is welcome.

 Casepresentation

30 yr male carpenter by occupation came to opd with

C/o shortness of breath since 10 days

C/o pedaledama since 10 days

C/o cough since 4days

C/o headache since 4 days

History of present illness

Pt is apparently asymptomatic 1 month back ,had dog bite on 1/06/2020 for which 3doses of vaccine was taken .

Later he developed pedal edema b/l pitting type progressed up to mid thigh

C/o sob since 10 days walking for some distance less than100 m

Orthopnea+

PND+

Sob decreased on lying to side

C/o of cough since 4 days,yellowish sputum,scanty,no hemoptysis

C/o headche since 4days,intermittent,

Occipitalregion, pricking type

No h/o vomitingd,loosestools,painabdomen,

Decreased urinary output

Bodypains+

History of past illness

Not a k/c/o DM,HTN,CAD,Bronchialasthma

Thyroid,TB,epilepsy

No h/o any surgeries in the past

Personalhistory

Appetite normal

Sleep adequate

Diet  - mixed

Bowel and bladder-regular

drug history

No known allergies to drugs

Family history

Not significant

General examination

Pt is consious,coherent cooperative,moderately built and nourished

Temp - afebrile

Pulse -110 bpm

Bp-130/60 mmhg

Rr-32 cpm

Grbs-129mg/dl

Spo2-97%

No pallor

No clubbing

No cyanosis

No koilonychia

No lymphadenopathy

Oedema -b/l pitting type present

CVS

Inspection

Shape of chest-bilaterally symmetrical

Trachea-central in position

Jvp -raised

Apical impulse in 6th ics lateral to midclavicular line

Precordial and epigastricpulsations+

No visible scars,sinuses,engorged veins

Palpation

Apexbeat-6th ics 2 inches lateral to the

Midclavicular line,heaving ,sustained doubleimpulse+

Parasternal heave,grade2,over left parasternal line

No palpable thrill ,no tenderness

Percussion

Dullness noted from left2nd ics medial to parasternal line up to apex

Auscultation

S1,s2 heard in pulmonary,mitral,tricuspid areas

Nomurmurs

Respiratory

Normal vesicular breath sounds, 

Bilateral air entry

Trachea - central

Wheeze - absent

Crepts/rales+

Abdomen

Shape-scaphoid

No tenderness

No palapablemass

No freefluid

Hernial orifices - normal

Liver and spleen-not palpable

CNS

Concsious

Speech - normal

No signs of meningeal irritation

Cranial nerves- intact

Sensorysystem- normal

Motorsystem- normal

Investigations

Serum electrolytes

Serum albumin

Serum bilurubin

CUE

Hemogram

ECG

2DECHO

HBsAg rapid

AntiHCVAntibodies-rapid

HIv1/2 rapid test

Serum pottasium

Provisional diagnosis:

Heartfailure with preserved ejection fraction with pericardial effusion.

Treatment:

Inj lasix40 mg iv tid

Inj pantop 40 mg iv od

Syrup potchlor 15 ml in 1 glass of water tid

Bp monitoring halfhourly

Strict input/output charting

Pr,spo2,grbs montioring

Head end elevation