1st internal examination

Comments

Post a Comment

Popular posts from this blog

24.prannai reddy

Image
  GENERAL MEDICINE E-LOG October 04, 2021 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.  NOTE: This is an ongoing case, the ELOG will be updated as and when we get the new information.  CHIEF COMPLAINT: A 65 year old male came to opd with the chief complaints of  Pedal edema and  Dyspnea on exertion( Grade III) since 10 days  HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic 10 days back, then he developed pedal edema and he was having dyspnea on exertion which is of grade III.  No bleeding manifestation No c/o burning micturition  No c/o cough, cold, headache HISTORY OF PAST ILLNESS: He was diagnosed with Acute K...
Read more

ALTERED SENSORIUM (RESOLVED)SECONDARY TO SEPSIS- SEPTIC ENCEPHALOPATHY WET GANGRENE OF LEFT 3RD TOE- S/P DISARTICULATION OF 3 RD TOE ON 10-08-2023 WITH CELLULITIS OF LEFT LEG WITH UNCINTROLLED SUGARS WITH THYOE II DM AND HTN WITH ANAEMIA (NCNC)

Case History and Clinical Findings  C/O ALTERED SENSORIUM SINCE 3 DAYS C/O ULCER OVER LEFT FOOT SINCE 3 MONTHS C/O BURNING MICTURITION SINCE 15 DAYS  HOPI : PATIENT WAS APPARENTLY ASYMPTOMATIC 1 MONTH AGO AND HE HAD ULCER OVER THE LEFT FOOT-3RD TOE NO H/O TRAUMA,INJURY BURNING MICTURITION SINCE 15 DAYS,ALTERED SENSORIUM SINCE 3 DAYS H/O IRRELAVANT TALK,NOT ABLE TO RECOGNISE ATTENDERS9ALTERED SENSORIUM MORE DURING EVENING) N/H/O FEVER,VOMITING,LOOSE STOOLS,PAIN ABDOMEN,GIDDINESS  PAST HISTORY: K/C/O TYPE 2 DMSINCE 25YRS ON INJ HUMAN MIXTARD 10-100 SINCE 20 YRS K/C/O HTN SINCE 20 YRS ON TAB TELMA-H PO/ODPERSONAL HISTORY : SLEEP-ADEQUATE DIET-MIXED APETITE-NORMAL ADDICTIONS-OCCASIONAL ALCOHOL CONSUMPTION ,H/O SMOKING ,STOPPED 1 YR BACK ALLERGIES-NONE O/E PATIENT IS CONSCIOUS, IRRITABLE, ORIENTED TO TIME, PLKACE, PERSON NO SIGNS OF PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,PEDAL EDEMA  VITALS : TEMP-96.8 F BP-120/70 MMHG PR-78 BPM GRBS-171 MG/DL SPO2-97 ON RA CVS ...
Read more

ALTERED SENSORIUM SECONDARY TO ? SEPTIC ENCEPHALOPATHY WITH UTI ? TB MENINGO ENCEPHALIIS WITH PRE RENAL AKI ON CKD WITH HEALING GLUTEAL ABSCESS WITH HTN WITH LATE ONSET PSYCHOSIS WITH ANEMIA OF CHRONIC DISEASE WITH GRADE II BEDSORE WITH HYPOKALEMIA

Case History and Clinical Findings  PT C/O FEVER,ALTERED SENSORIUM,LOSS OF APPETITE SINCE 2 DAYS. PT WAS APPARANTLY ASYMPTOMATIC 2 DAYS AGO THEN SHE HAD FEVER WHICH WAS HIGH GRADE, NOT ASSOCIATED WITH CHILLS, RIGORS.RELIEVED WITH MEDICATION.NO DIURNAL VARIATION. ALTERED SENSORIUM SINCE 2 DAYS. IRRELEVANT BLACK OUT , NOT ABLE IDENTIFY ATTENDERS. NO H/O LOSS OF CONSCIOUSNESS,INVOLUNTARY MOVEMNENTS, WEAKNESS IN BOTH UPPER AND LOWER LIMBS.LOSS OF APPETITE PRESENT N/H/O CHEST PAIN,SOB,PALPITATIONS,PEDAL EDEMA. N/H/O COUGH,BURNING MICTURITION K/C/O HTN ON TAB.ATENOLOL K/C/O CKD ON CONSERVATIVE MANAGEMENT K/C/O AKION CKD SECONDARY TO RUPTURED GLUTEAL ABSCESS WITH K/C/O LATE ONSET PSYCHOSIS H/O BLOOD TRANSFUSION- FFP TRANSFUSION GENERAL EXAMINATION- PT IS DROWSY AROUSABLE WITH DEEP PAIN STIMULATION NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,OEDEMA.  BP: 100/60MMHG PR : 98BPM RR : 24 CPM SPO2 : 97% GRBS : 148 MG% I/O : 2500/1300 SYSTEMIC EXAMINATION  CVS : S1 S2 HEARED ,N...
Read more