145 Dilliswar Veebhuthi

GENERAL MEDICINE CASE PRESENTATION

Dilliswar Veebhuthi

3rd sem; roll no.145

Under the guidance of Dr. Manasa (intern)

This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission.

I have 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.

CASE SCENARIO

A 15 yr old patient (student by occupation) came to the casualty with chief complaints of pain in the left side of chest since 1 month,fever intermittent in nature (dull type)

•HISTORY OF PRESENT ILLNESS

-Patient was apparently asymptomatic 2 months back and had pain on left side of sternum radiating to left arm.

-Initially mild pain which subsides by it's own but he has moderate pain.

-No h/o palpitations,giddiness,sweating,SOB,blurring of vision,headache,pain radiation with food intake.

•HISTORY OF PAST ILLNESS

-h/o snake bite 6 years ago.

-not a diabetic, hypertension, epilepsy,TB.

•PERSONAL HISTORY

-patient is a student by occupation has a normal appetite with mixed diet.

-he has normal bowels and micturition.

•FAMILY HISTORY

-No familial history.

•GENERAL EXAMINATION

-No- pallor/Icterus/cyanosis/clubbing/oedema/malnutrition/lymphadenopathy/dehydration

-BP:120/70 mm Hg

-PR:72 beats /min.

-RR:20/min.

-RPO2:100 RA

-GRBS:142mg/do

•SYSTEMIC EXAMINATION

CVS

No Thrills

*Cardiac Sounds - S1, S2 +

*No cardiac murmurs

RESPIRATORY SYSTEM     

*Dyspnoea - No

*No Wheezing

*Position of Trachea - Central

*Vesicular sounds  

ABDOMEN   

*Shape - scaphoid

*No tenderness, palpable mass, No free fluid, No bruits 

*Yes bowel sounds

*Hernial Orifices - Normal

*Liver, Spleen - Not palpable

*Genitals, speculum examination, PV examination, P/R examination - Normal

CENTRAL NERVOUS SYSTEM         

*Level of consciousness - conscious

*Speech - Normal

*No signs of Meningeal Irritation

*Cranial nerves - Normal

*No motor or sensory deficit

•INVESTIGATIONS

ECG



•PROVISIONAL DIAGNOSIS

-Acid Peptic Disease

•TREATMENT

-Inj. Pantop 80 mg in 100 ml NS IV/STAT

-T. PAN-D PO/OD × 1 week

-SYP.  SUCRALFATE  15 ml PO/TID

-SYP. MUCAINE GEL 5ml PO/TID

-T. MVT PO/OD

-T. MYORILL 8 mg PO/TID.















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