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.

70 yr old male patient, carpenter by occupation presented with difficulty in swallowing and pain during eating and while bending forward since 15 days

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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