40years old male with community acquired pneumonia with right upper lobe, middle lobe ,lower lobe consolidation and left upper lobe.


40 years old male with community acquired pneumonia with right upper lobe,middle lobe,lower lobe consolidation and left upper lobe

September 16, 2022

Hello, I am. U.Sravani,a 3rd semester medical student. This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio


 40 years old male resident of nalgonda who is farmer came to the hospital with the complaints of 


CHIEF COMPLAINTS
C/o  Fever since 3 days 
C/o cough (dry cough) since 3days 
C/o shortness of breath grade 4 since 3 hours 


HISTORY OF PRESENTING ILLNESS
Patient  was apparently asymptomatic  3days ago then he had fever  associated with chills and rigors  then he developed dry cough,And then developed SOB Grade 4 since 3 hours.
No h/o cold, nausea, vomiting, loose stools.



PAST HISTORY
Not a known case of
Diabetes 
Hypertension
Tb 
Asthama
Epilepsy
Cvd
Chemotherapy

FAMILY HISTORY
Not significant
PERSONAL HISTORY
Diet - mixed
Appetite - Decreased 
Bowel and bladder - adequate
Allergies -odlu dust
Addiction -  intake of alcohol 
90ml daily 


GENERAL EXAMINATION
Thin built and malnourished 

Vitals
Temperature : Afebrile 
Pulse: 90
BP:120/70 mm/ hg
RR :26
SPO2 : 92%

Pallor : ABSENT 
Icterus : ABSENT 
Clubbing :ABSENT
Cyanosis :absent
Lymphadenopathy: absent
Pedal edema: absent

SYSTEMIC EXAMINATION
CVS
Apex beat 6 th intercoastal space
No thrills
S1 S2 heard
No murmurs

ABDOMEN EXAMINATION


RESPIRATORY SYSTEM

dyspnoea wheeze+
Central trachea 
Bilateral air entry +
Bilateral basal crepts +

Investigation 













Popular posts from this blog

A 35 year old female with headache and hearing loss

Image
A 35 year old female, resident of Nalgonda , farmer by occupation came to hospital on 19/9/22 with  CHIEF COMPLAINTS         Headache and neckpain since 6 months .  Headache was on and off and associated with vomitings. She complaints of hearing loss and tinnitus in right ear and giddiness since 1 month. HISTORY OF PRESENT ILLNESS        The patient was apparently assymptomatic 6months ago.The she had headache associated with neck pain and vomitings.  She complaints of hearing loss and tinnitus in right ear and giddiness while head movement since 1 month. She has no history of fever or chills. No history of ear discharge. PAST HISTORY        No history of DM       No history of HTN        No history of CAD , Asthma , epilepsy, TB  FAMILY HISTORY           No History of DM , HTN ,CAD , TB , Asthma  PERSONAL HISTORY       ...
Read more

case -11

Image
A 65 yr old male patient came to OPD  with fever and chills This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. 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 diagnosis and treatment plan. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we di...
Read more

A case of diabetic ketoacidosis and nausea, vomiting with bilateral upper and lower limb edema and facial puffiness in a 55 year old female patient.

Image
Case 11 A case of diabetic ketoacidosis and nausea, vomiting with bilateral upper and lower limb edema and facial puffiness in a 55 year old female patient. June 05, 2023 A case of diabetic ketoacidosis and nausea, vomiting with bilateral upper and lower limb edema and facial puffiness in a 55 year old female patient. Hi, I am U.Sravani, 5th semester medical student. This is an online elog book to discuss our patients health data after taking their consent. This also reflects my patient centered online learning portfolio. Case Scenario A 55 year old woman from Nalgonda came to OPD on 3rd of June with chief complaints of: - bilateral upper and lower limb edema since 10 days - nausea since 1 week. History of Presenting Illness - patient was apparently asymptomatic 10 days ago when she developed edema in bilateral upper and lower limbs and facial puffiness for which she consulted a local physician and was prescribed medication following which the symptoms subsidised but relapsed again 1 w...
Read more