General Medicine

1st,September, 2022.

A 47 year old female with extrapulmonary Tuberculosis,Hypertension, Diabetes mellitus. 
E LOG GENERAL MEDICINE 

Hi, I am Pindi Gayatri, 3rd Sem Medical Student.This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed 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 E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.”

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

CHIEF COMPLAINTS 
A 47 year old female came to hospital with the chief complaints of shortness of breath since 10 days (increased).
Itching generalised from August 1st week.
Back pain since 7 days.
Abdominal pain since 7 days.Admitted on 29th ,August. 

HISTORY OF PRESENT ILLNESS 
History of giddiness 6 years ,sought for consultation and diagnosed with type 2 Diabetes mellitus ,initially on OHA'S(4 years).shifted to insulin (2 years).
       History of pedal edema, sought for consultation, took medications, pedal edema resolved.
      After a month Abdominal distension,
      last week of june- complaints of abdominal distension and SOB,sought for consultation, cervical lymphadenopathy. 

HISTORY OF PAST ILLNESS 
Known case of type2 DM since 6 years,giddiness
      Known case of hypothyroidism and hypertension since 5 months.
      Diabetic nephropathy
       Bilateral pedal edema 
       S/P tubectomy(LA) 20 years ago

TREATMENT HISTORY 
Diabetes present
Hypertension present 
No CAD
No Asthma
Tuberculosis-extrapulmonary TB since 9/7/22,medication 21/7/22
Antibiotics used
No hormones 
No chemo/Radiation 
No Blood transfusion 
Surgeries-tubectomy s/p

PERSONAL HISTORY
 Married 
Occupation-home maker
Diet-mixed
Appetite-normal-(if she ate ...SOB increased)
Bowels-irregular-slight hard stools
Micturition-abnormal 
Allergies-generalised itching by the end of 1st week of August. 

FAMILY HISTORY 
Diabetes-mother
No hypertension 
No Heart disease 
No stroke 
No cancers
No Tuberculosis 
No asthma 

MENSTRUAL HISTORY 
LMP-Attained menopause at the age of 44 years.

GENERAL EXAMINATION 
No pallor
No icterus 
No cyanosis
Clubbing of fingers is present 
Oedema of feet-grade 2
Malnutrition 
Mild dehydration 
Dark pigmented tongue


SYSTEMIC EXAMINATION 
CVS
No thrills
S1S2 sounds heard 
No cardiac murmurs 
RESPIRATORY SYSTEM 
Position of trachea-central 
Vesicular breath sounds heard 
Dyspnea -grade 2 (NYH4)
No wheeze 
ABDOMEN
Shape of the abdomen-distended
No tenderness 
No palpable masses
Normal hernial orifices 
free fluid-gross ascites 
No bruits
Non palpable liver
Non Palpable spleen
Bowel sounds are heard
Speculum examination, PV examination, P/R examination-normal
CNS
Level of consciousness- conscious/alert
Speech- normal 
Signs of meningeal irritation 
         stiffness of neck :no
          Kerning's sign:negative 

Reflexes
        Plantars-flexor 

Cerebellar Signs 
Finger nose In-coordination- no 
Knee heel In-coordination - no

PROVISIONAL DIAGNOSIS 
Low protein  low SAAG ascites 2°to TB with diabetic nephropathy 
      Known case of hypothyroidism/type 2 DM/Hypertension. 

INVESTIGATIONS 
On 29th, August 
On 30th, August 
                   Ultrasound report 

RECORDINGS 
DIAGNOSIS 
Drug induced pruritis(ATT drugs)

TREATMENT

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