GENERAL MEDICINE

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.


#This  is an ongoing case , and will be updated as and when the information is provided

CASE SCENARIO

A 60 yrs old male patient was Auto driver by occupation came to OPD with the C/o constipation since 2 months pedal oedema from 15 days SOB for 15 days 
and cough for 7days 


HISTORY OF PRESENT ILLNESS 
Pt was apparently asymptomatic 6 yrs back and had c/o constipation and blood in stools and underwent medication for 1 month and haemorroids subsided 
4 yrs back pt had sever vomitings and giddiness which  diagnosed with DM and HTN and prescribed medicines and patient was on medication since then 
Now since 15 days pt is having B/L pedal oedema pitting type with burning micturation. No h/o of fever. Urination not associated with urgency frequency hesitancy.
SOB since 15 days grade 2 with chest pain with Paroxysmal nocturnal dsypnea and orthopnea 
Constipation since 2 months 
Cough from 7 days wet cough with white sputum 

HISTORY OF PAST ILLNESS
k/c/o DM and HTN
No k/c/o Asthma /CAD
At 9yrs of age pt had yellowish discoloration of the eye since then he used to have jaundice on/off. 

TREATMENT HISTORY 
Diabetes medication
HTN medication 
Blood transfusion last month 

PERSONAL HISTORY 
Loss of appetite
Constipation
Normal micturation
Occasional alcohol consumption
Chewable tobacco (thambaku ) since 30 yrs 

ALLERGIC HISTORY  
No know allergies 

FAMILY HISTORY 
No familial history

GENERAL EXAMINATION 
 No Signs of Icterus 
 No Signs of Cyanosis
 No Clubbing
 No Lymphadenopathy
 Oedema present - pedal oedema 
 Pallor present 

VITALS 
TEMP- Afebrile 
BP - 110/60 mmHg
PR - 82bpm 
GRBS- 119mg /dl


SYSTEMIC EXAMINATION

CVS 
No thrills 
S1 S2 +
No Murmurs

RESPIRATORY
No dyspnoea 
No wheeze 
Trachea central 
Vesicular breath sounds 

ABDOMEN 
Scaphoid shape 
No tenderness 
No palpable mass
Liver not palpable 
Spleen not palpable 
Bowel sounds present 
P/R Examination - haemorroids grade 2 

CNS 
Conscious
Normal speech 
No neck stiffness 
No kerning's sign
 
INVESTIGATIONS

     Hemogram 
.   ECG
 
 USG  
Impression
Diffuse urinary bladder wall thickening with tuberculations and diverticuli 
Significant PVR noted  
Raised echogenicity of b/l kidney
Spleenomegaley 

PROVISIONAL DIAGNOSIS

Anemia 2 ° to blood loss with grade 2 Haemorroids 

TREATMENT  
6/07/22
IM IRON SUCROSE 200mg in 100 ml NS IV od 
INJ OPTINEURON 1amp in 100 ml NSNS/IV /OD 
SITZ BATH with BETADINE /TID
ONT ANOBI for LA before and after defecation
ISPHAGLUS GRANULES/BD 
Tab MONTEX - LC Po/OD 
Tab DOlO 650 mg  Po/ TID 
SYP ASCORIL- D 15 ml TID 
TAB AMLONG + ATEN (5/50)
TAB GLIMI M1 (500) Po/OD 
Monitor vitals 
Inj Kcl 1 amp in 500 ml NS IV/ stat 

7/07/22
INJ OPTINEURON 1amp in 100 ml NSNS/IV /OD 
SITZ BATH with BETADINE /TID
ONT ANOBI for LA before and after defecation
ISPHAGLUS GRANULES/BD 
Tab MONTEX - LC Po/OD 
Tab DOlO 650 mg  Po/ TID 
Syp ASCORIL -D 15 ml Po/ TID 
Tab GLIMI M1  Po/OD 

VITALS 

06/07/22
TEMP- Afebrile 
BP- 110/60mmHg
PR- 82bpm
GRBS- 119ml/dl  

07/07/22
TEMP - Afebrile 
BP - 110/70 mmHg
PR - 78bpm 
GRBS- - 114ml/dl 

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