June 26,2020

Hello everyone...  I am sivani an intern in the medicine department and of the important  terms of getting the internship completion is to complete my log book with my online log of what i have learnt during my clinical course.
       "This is an online e log book to discuss our patients deindentified health data sharing after his/ hers guardians signed informed consent.
          Here we discuss our indi6vidual patients problems through a series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current evidence based inputs.
            This elog also reflects my patient centered online learning portfolio and your valuable inputs on the comments box is welcome.
 Casepresentation
30 yr male carpenter by occupation came to opd with
C/o shortness of breath since 10 days
C/o pedaledama since 10 days
C/o cough since 4days
C/o headache since 4 days
History of present illness
Pt is apparently asymptomatic 1 month back ,had dog bite on 1/06/2020 for which 3doses of vaccine was taken .
Later he developed pedal edema b/l pitting type progressed up to mid thigh
C/o sob since 10 days walking for some distance less than100 m
Orthopnea+
PND+
Sob decreased on lying to side
C/o of cough since 4 days,yellowish sputum,scanty,no hemoptysis
C/o headche since 4days,intermittent,
Occipitalregion, pricking type
No h/o vomitingd,loosestools,painabdomen,
Decreased urinary output
Bodypains+
History of past illness
Not a k/c/o DM,HTN,CAD,Bronchialasthma
Thyroid,TB,epilepsy
No h/o any surgeries in the past
Personalhistory
Appetite normal

Sleep adequate
Diet  - mixed
Bowel and bladder-regular
drug history
No known allergies to drugs
Family history
Not significant
General examination
Pt is consious,coherent cooperative,moderately built and nourished
Temp - afebrile
Pulse -110 bpm
Bp-130/60 mmhg
Rr-32 cpm
Grbs-129mg/dl
Spo2-97%
No pallor
No clubbing
No cyanosis
No koilonychia
No lymphadenopathy
Oedema -b/l pitting type present
CVS
Inspection
Shape of chest-bilaterally symmetrical
Trachea-central in position
Jvp -raised
Apical impulse in 6th ics lateral to midclavicular line
Precordial and epigastricpulsations+
No visible scars,sinuses,engorged veins
Palpation
Apexbeat-6th ics 2 inches lateral to the
Midclavicular line,heaving ,sustained doubleimpulse+
Parasternal heave,grade2,over left parasternal line
No palpable thrill ,no tenderness
Percussion
Dullness noted from left2nd ics medial to parasternal line up to apex

Auscultation
S1,s2 heard in pulmonary,mitral,tricuspid areas
Nomurmurs


Respiratory
Normal vesicular breath sounds, 
Bilateral air entry
Trachea - central
Wheeze - absent
Crepts/rales+
Abdomen
Shape-scaphoid
No tenderness
No palapablemass
No freefluid
Hernial orifices - normal
Liver and spleen-not palpable
CNS
Concsious
Speech - normal
No signs of meningeal irritation
Cranial nerves- intact
Sensorysystem- normal
Motorsystem- normal
Investigations

Serum electrolytes
Serum albumin
Serum bilurubin
CUE
Hemogram
ECG
2DECHO
HBsAg rapid
AntiHCVAntibodies-rapid
HIv1/2 rapid test
Serum pottasium

Provisional diagnosis:
Heartfailure with preserved ejection fraction with pericardial effusion.
Treatment:
Inj lasix40 mg iv tid
Inj pantop 40 mg iv od
Syrup potchlor 15 ml in 1 glass of water tid
Bp monitoring halfhourly
Strict input/output charting
Pr,spo2,grbs montioring
Head end elevation


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