GM e-log

GENERAL MEDICINE ELOG
Hi, This is Rithika, a fifth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from  patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them

65 YR OLD FEMALE WITH ATRIAL FIBRILLATION WITH MODERATE MR WITH HFpEF
? MESENTERIC ISCHAEMIA
? CLINICAL MALARIA

CHIEF COMPLAINTS :

C/O fever since 10 days
C /O SOB since 5 days

HOPI :

Patient was apparently asymptomatic until 10 days back, then she developed fever, high grade associated with chills and rigor, continuous, relieved on medi ation, diurnal variation, more during night. 
Then she had insidious onset SOB of grade I, progressed gradually to grade IV. 
H/O palpitations and occasional chest pain +
H/O abdominal bloating sensation +
H/O pedal edema +
No H/O profuse sweating
H/O cough, non- productive since 5 days
No H/O hematuria, burning micturition, pain abdomen, constipation  , loose stools, decreased urine output  , facial puffiness

PAST HISTORY :

K/C/O HTN since 2 yrs, on T. Amlodipine
N/K/C/O DM, CVA, CKD, CAD, TB, epilepsy, asthma, thyroid
Hysterectomized 12 yrs back
H/O blood transfusion 12 yrs back

PERSONAL HISTORY :

Daily wage worker by occupation
Normal appetite
Mixed diet
Regular bowel and bladder movements
Consumes toddy since 40 yrs

GENERAL EXAMINATION :

Patient is conscious, coherent, cooperative
Cyanosis + ( on lips) 
No pallor, icterus, clubbing, Lymphadenopathy, edema

Vitals :
BP 140/90 mmHg
PR 128 bpm
Temp 98.6°F
RR 24 cpm
GRBS 140
Spo2 95%


SYSTEMIC EXAMINATION :

CVS  :
S1, S2 +
No murmurs

RS :
BAE +
No dyspnoea
Trachea - central
NVBS +

P/A :
Shape - obese
No tenderness
Spleen and liver not palpable
Bowel sounds heard

CNS :
NFND


DIAGNOSIS :
ATRIAL FIBRILLATION WITH HFpEF
? MESENTERIC ISCHAEMIA
? CLINICAL MALARIA



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