GENERAL MEDICINE BLOG-2

General Medicine Case Discussion

December 19, 2022
 General medicine case discussion

E LOG MEDICINE CASE

20/12/2022

This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed consent.Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence-based inputs.This e-log book also reflects my patient centered online learning protfolio and your valuable inputs on comment box is welcome.

Name : J.Rajarajeshwari
Roll no : 51

2020 Batch

I''ve 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 comeup with Diagnosis and Treatment plan General medicine case discussion

CASE DISCUSSION:

Date of admission:17/12/2021

A 45 year old female came to opd who is a farmer came with ,

CHEIF COMPLAINTS:
Known case of renal failure came for dialysis. 
 
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 2 months back then she developed lower back ache associated with pitting edema and dyspnea.Pain got relived on sleeping. Then she approached local hospital in Miryalaguda there they daignosed it as renal failure. so she came here for dialysis. She has productive cough since four days. 

PAST HISTORY : 
Known case of hypertension since 2 months. 
There is no history of DM,TB, EPILEPSY.
No history of blood transfusions. 
No history of previous surgeries. 

PERSONAL HISTORY:
Appetite : Normal appetite 
Diet : Mixed 
Bowel and bladder movements : Regular 
Sleep : Decreased sleep since 2 months 
Addictions: None 
 
FAMILY HISTORY:
No family history of DM,HTN,TB,epilepsy

GENERAL EXAMINATION:

Conscious, coherent, co-operative
Moderately built,nourished

PALLOR: Present 


ICTERUS: Absent 
CYANOSIS: Absent 
CLUBBING OF FINGERS/TOES: Absent 
LYMPHADENOPATHY: Absent 
PEDAL EDEMA: Pitting edema is present. 

VITALS:
TEMPERATURE: 
PULSE RATE:98 beats /min
RESPIRATORY RATE:18 Cycles/min
BP:140/80mm of hg 
SPO2:98% at room air
GRBS:90mg%


SYSTEMIC EXAMINATION:

CVS:
S1,S2 Sounds heard,
No audible murmurs,


RESPIRATORY SYSTEM:
Dyspnea is present,
Position of trachea:central,
Normal vesicular breath sounds are heard,
No adventitious sounds  

ABDOMEN:
Shape of abdomen-scaphoid
No tenderness
No palpable mass
Normal hernial orifices
No free fluid
Liver and spleen are not palpable
Bowel sounds are heard

CNS:
Conscious 
Normal speech 
Cranial nerve examinationis normal
Motor system is normal
Sensory system is normal
INVESTIGATIONS :
16/12/2022
COMPLETE URINE ANALYSIS :

16/12/2022
COMPLETE BLOOD PICTURE 

17/12/2022
LFT:

16/12/2022
BLOOD UREA :

16/12/2022
SERUM CREATININE :

16/12/2022
RBS:

PROVISIONAL DIAGNOSIS:
Chronic renal failure with known case of hypertension

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