70 yr old male patient, carpenter by occupation presented with difficulty in swallowing and pain during eating and while bending forward since 15 days
E LOG GENERAL MEDICINE.
Hi, I am G Sai Karthik, 6th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.
- This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING.
- * This is an ongoing case. I am in the process of updating and editing this ELOG as and when required
CASE SHEET.
Chief complaints and duration.
History of present illness.
Patient was apparently asymptomatic 15 days back. He developed pain in the chest and difficulty in swallowing. Pain was gradual, non progressive. It was aggrevated on eating.Patient drink water to flush down the bolts
Chest pain was also present when bending forward mainly after meals
History of past illness.
Patient had burning micturition 30 days back, consulted doctor and had been taking medication.
Patient experiences breathlessness due to wood dust, using medication
No HTN
No DM
No asthma
No TB
No CAD
No Syphilis
No CVA
Family history.
No significant family history
Allergies.
Not significant
Drug history.
Patient using inhalational steroids when experiencing breathlessness
Antibiotic meropenem for urinary tract infection since 20 days
Mirabig s since 20 days
Silotrib d since 20 days
Personal history..
Appetite is reduced due to dysphasia and odynophagia
Mixed diet
Bowel and bladder movement is regular.
Sleepl adequate
occasional alcohol consumption
No addictions
PHYSICAL EXAMINATION.
A. General Examination
Conscious coherent and cooperative
Well built
No pallor
No Icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
No oedema .
Vitals.
Temperature: A febrile
Pulse: 90 bpm
Respiration: 16/min
Blood pressure: 125/70 mmhg
Spo2: 96%
SYSTEMIC EXAMINATION
Respiratory system
Inspection
No scars observed
Chest size, shape , symmetry normal
Trachea position normal
Palpation
All inspectors findings confirmed
Percussion
All areas resonant on percussion
Auscultation
Vesicular lung sounds heard at all areas
CVS
S1 S2 heard
No murmurs or abnormal sounds
CNS
All higher neurological functions preserved
PER ABDOMINAL
No organomegaly
Treatment
Syrup Sucral O 10 mL three times a day for 10 days
Tab Rantac 150mg twice daily for 10 days
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