05 Akula Vignesh

 Date of admission:- 30 june 2022 CASE SCENARIO  Pt aged 45 yrs F daily wage worker came to opd with chief c/o bilateral pedal edema since 20 days and SOB on exertion since 20 days HISTORY OF PRESENT ILLNESS Pt has bilateral pedal edema ( pitting)  and SOB on exertion  HISTORY OF PAST ILLNESS N/k/c/o Dm and HTN TREATMENT  HISTORY  Pt is not on any medication PERSONAL HISTORY  Married Mixed diet Daily wage worker  PHYSICAL EXAMINATION  Patient is conscious, coherent and cooperative • Moderately built and Moderately nourished • No signs of - Pallor                        Cyanosis                        Clubbing                        Icterus Edema is present,pitting type VITALS • Temp -  •Pulse rate - 82 BPM •RP -  •BP - 130/70 mm hg •SPO2 -  SYSTEMIC EXAMINATION CARDIOVASCULAR SYSTEM • S1, S2 heard • No murmurs RESPIRATORY SYSTEM:   •Position of trachea - central •Breath sounds - vesicular ABDOMEN •Shape - scaphoid • palpable liver •Spleen is not palpable  CENTRAL NERVOUS SYSTEM: • Inta

  CASE SCENARIO Pt aged 60 yrs M farmer by occupation came came opd with chief complaints of SOB 10 days and decreased loss appetite since 10 days and sleep disturbances since 10 days lower backache since 10 days Fever since 4 days. HISTORY OF PRESENT ILLNESS •Pt was apparently normal 9 yrs back then developed HTN; •1 yr back pt developed lower flank pain on both sides went toprivate hsptl then since Aug 2021 then pt was on dialysis  •3 yrs back pt had a seizure on midnight in sleep and since then he was on PHENYTOIN   HISTORY OF PAST ILLNESS Pt know case of HTN since 9 yrs Pt is on femoral line since August 2021 N/k/c/o DM TREATMENT  HISTORY  Pt is on hypertensives and PHENYTOIN  PERSONAL HISTORY  Mixed diet Occasional alcohol drinker PHYSICAL EXAMINATION  Patient is conscious, coherent and cooperative • Moderately built and Moderately nourished • No signs of - Pallor                        Cyanosis                        Clubbing                        Icterus VITALS • Temp - afebril

  CASE SCENARIO Pt aged 28 years female house wife came to opd with chief complaints of loose stools since 20 days associated with abdominal pain and generalised  Weakness since 10 days HISTORY OF PRESENT ILLNESS   It was asymptomatic 30 days back then when  stools started which is less in quantity assosiated with abdominal pain that relevied after patting stools not associated with any blood in stools associated with generalised weakness  HISTORY OF PAST ILLNESS   No H/o DM, HTN, Asthma , epilepsy, TB .  she had 3 c section before . TREATMENT HISTORY  NO history of previous medication   PERSONAL HISTORY  Married  Mixed diet  Loss of appetite  Irregular bowel habit  Regular mensus  FAMILY HISTORY  NO H/O :-HTN,DM ,EPILEPSY ,TB  GENERAL EXAMINATION  NO pallor         .icterus         .cynosis         .lymphadenopathy         .clubbing  PHYSICAL EXAMINATION-: .temperature-:afibrile  .pulse rate  -:82/min .resp rate -:18/min  .Bp             -:90/70   SYSTEMIC EXAMINATION  CVS-;         

CASE SCENARIO  PT aged 40 yrs F Farmer by occupation came to opd with c/o of Vomitings since 15 days nausea since 15 days Pt was apparently normal 4yrs back then she had burning micturition pedal edema and rt loin pain and diagnosed with renal calculi(2 to 3 cm) Pt has right kidney nephrectomy in 2018 HISTORY OF PRESENT  ILLNESS Since 10 to 15 days pt had nausea and Vomiting  HISTORY OF PAST ILLNESS Right kidney nephrectomy in 2018 N/k/c/o BP and HTN PERSONAL HISTORY  Mixed diet Married Farmer by occupation  PHYSICAL EXAMINATION  Patient is conscious, coherent and cooperative • Moderately built and Moderately nourished • No signs of - Pallor                        Cyanosis                        Clubbing                        Icterus VITALS • Temp - 98.4F •Pulse rate - 82 BPM •RP - 16 /min •BP - 130/70 mm hg •SPO2 - 98 SYSTEMIC EXAMINATION CARDIOVASCULAR SYSTEM • S1, S2 heard • No murmurs RESPIRATORY SYSTEM:   •Position of trachea - central •Breath sounds - vesicular ABDOMEN •Shape -

CASE SCENARIO  A 63yr old male patient came to opd with chief complaints of Sleep disturbances and Low mood since 1 year History of present illness Pt developed skin lesions on ankle following which spread to Lower limb..pt was diagnosed with psoriasis 1 yr back Due to spread of lesions to most of the body pt liked to be in home rather going out and and he liked to be alone since then he had sleep disturbances and Low mood.. History of past illness Chronic plaque psoriasis since 1 yr N/k/c/o -htn,dm Personal history  Pt drinks alcohol since 35 yrs 2 to 6 units And smokes since 35 yrs Mixed diet Treatment History  Pt is on Treatment for psoriasis  GENERAL EXMINATION: Patient is conscious, coherent Absence of: pallor                       icterus                       clubbing                       cyanosis                       pedal edema                       lymphadenopathy. VITALS :  Temperature: 98 F Pulse rate: 85 beats per min Respiratory rate: 16 cycles per min  BP: 120/70mm Hg

CASE SCENARIO  Patient aged 62 yrs,toddy Tree climber by occupation came to opd with complaints Of loss of appetite and nausea since one week, Decreased urine output since 5 days And SOB on exertion and B/L limb swelling since a week HISTORY OF PRESENT ILLNESS Since a week pt has loss of appetite and nausea  SOB on exertion and B/L limb swelling since a week Decreased urine output since 5 days HISTORY OF PAST ILLNESS Pt was apparently normal 4 yrs back then he developed weakness and pain of bilateral limbs and on medication with pain killers on which the pain was not subsided then xray of spine was done and pt was diagnosed with Decreased bone density (OSTEOPOROSIS) Pt diagnosed with HYPERTENSION and on hypertensives Not a k/c/o of DM,CAD TREATMENT HISTORY  Pt was on hypertensives and had a tablet daily once PERSONAL HISTORY Irregular bowel habit Decreased urine output Mixed diet  Occasional alcohol drinker Had smoking habit PHYSICAL EXAMINATION  Patient is conscious, coherent and coop

  This is A.VIGNESH of 5th semester.  This is an  online E log platform to discuss our patient's    de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan. Introduction -  Patient aged 28years was bought to casuality with h/o giddiness and headache and decreased reaponsivness. -History of ratpoison consumption 4days back and discharged back. Chief complaints -Pt has h/o zinc posphide poisoning on 3rd june 2022 and pt was admitted on 3rd june and was treated conservatively and was discharged on 6th june. -Pt was normal on 6th and 7th june. HISTORY OF PRESENT ILLNESS • On 8th june Pt had headache and decreased appetite and 1 episode  of fever, no chills  -Then pt went to bed and had history of difficulty in sp