General Medicine elog

Gm e-log

July 07, 2022

This is online E log book to discuss our patients health data shared after taking his guardians informed consent form

I have been given this case to solve in an attempt to understand topic of" patient clinical data analysis" to develop my competency in reading and comprehensing clinical data including history clinical findings

 investigations and come with a diagnosis and treatment plan. 

A 47 yr old female housewife by occupation came to OPD with chief complaints of pedal oedma  abdominal distension and shortness of breath since 2months.

History of present illness:

She was apparently asymptomatic 6yrs back and had generalised Body Weakness for which she came to the hospital and was diagnosed with DM-2 and was on regular medication. 2 months Back pt had pedal edema B/L below Hip Pitting type and abdominal distension for which she visited nearby hospital and was diagnosed with hypertension and hypothyroidism after necessary tests , pedal edema was subsided with medication but abdominal distension was not subsided for which She Came to our Hospital,admitted and treated for 1 week for low SAAG low Protein Ascites secondary to Koch's diabetic nephropathy. FNAC was done and S/o of chronic granulomatous lymphadenitis.Now pt came for excisional biospy.

History of past illness:

K/c/o of DM : 6yrs on medication 

K/c/o of hypertension:2months back

K/c/o of hypothyroidism:2months back

Treatment History:

For diabetes on HAI 4U S/C TID

For hypertension Telmi 40mg OD

Personal History:

Diet : mixed

Appetite: Decreased

Bowel movement: regular

Micturition: Normal

Addictions: Nil

No allergic History 

Family history:

No relavent family history

General Examination:

Patient is conscious,coherent and co operative well oriented with time and place .

Well nourished and built

There are no signs of

Cyanosis

Pallor

Clubbing

Icterus 

There is presence of 

Lymphadenopathy 

Oedema present: B/L Pitting Type and anasarca

Palpable lymph node is present in the posterior triangle of neck 

VITALS:

Temperature: 98.6 degree Fahrenheit

Pulse rate: 76 per min

Respiratory rate: 16 per min

BP: 110/70 

SpO2: 96% 

Systemic Examination:

CARDIOVASCULAR SYSTEM 

slightly elevated jvp 

S1 S2 +

RESPIRATORY SYSTEM 

Dyspnoea : yes

Wheeze : no

Postion of trachea: central

Breath sounds: vesicular

ABDOMEN 

Distended 

Tenderness present 

Free fluid present 

Liver and spleen is not palpable

Bowel sounds are normal

  

CNS

Conscious with normal'speech

There is no sign of meningeal irritation

Glasgow scale 15/15

Investigations:

C-Reactive protein 

Random blood sugar 

Serum electrolytes 

ECG

Diagnosis:

  Low SAAG low Ascites secondary to diabetic nephropathy

Right lymphadenopathy - chronic granulomatous lymadenitis.

TREATMENT:

Inj LASIX 20 mg BD 

Tab TELMA 40 mg OD

Tab ULTRACET 1/2 QID

Tab OROFER OD

Inj HAI SC tid before meals

5/7/22 

No fever 

Same treatment given 

6/7/22

No fever 

7/7/22

Patient had slight fever 

Genrealised bodyy weakness 

8/7/22 

Generalised body weakness present 7