General medicine E log

This is online E book to discuss our patients health data shared after taking his guardians informed consent form

I have been  given this case to solve in an attempt to understand topic of" patient clinical data analysis" to develop my competency in reading and comprehensing clinical data including history clinical findings investigations and come with a diagnosis and treatment plan.
Case Scenario::
A 65 yr old male came to OPD with chief complaints of a Decreased urine output and Abdominal distension since 1 day Bilateral lower limb swelling which is pitting type since 10 days .

History of present Illness:-
-Decreased urine output, abdominal distension, not associated with pain. Bilateral pitting type since 10 days.
History of low grade intermittent fever not associated with chills, rigors since 10 days.

History of past Illness
K/c/o CKD,4 Cycles of Haemodialysis done
Known case of Hypertension and Diabetes

Treatment history
Using Medication for Diabetes since  5 yrs
Medication for hypertension since 2 yrs
Personal History
Diet : mixed
Appetite: losed
Bowel movement: losed
Micturition: Abnormal
Addictions: occasional Alcohol consumption, Smoking
Family history 
No relavent family history
General Examination 
Patient is conscious,coherent and co operative well oriented with time and place .
Well nourished and built

There are no signs of
Cyanosis
Lymphadenopathy
Clubbing

There is presence  of 
Pallor 
Oedema present 10 days back ,subsided now
VITALS
Temperature: 98.6  degree Fahrenheit
Pulse rate: 86 per min
Respiratory rate: 18 per min
BP: 130/80 
SpO2: 96% 
Systemic Examination
CVS
S1 S2 heared
No murmurs

RESPIRATORY system 
Dyspnoea : no
Wheeze : no
Postion of trachea: central

ABDOMEN 
No Tenderness
There is no free fluids
Liver and spleen is not palpable
Bowel sounds are normal

CNS
Conscious with normal'speech
There is no sign of meningeal irritation
Glasgow scale 15/15



Investigations::-

On 04/07/2022
Random Blood sugar
Blood urea
Serum creatinine
Serum electrolytes

On 05/07/2022
HBsAg

HIV

Anti HCV Antibodies
Ultrasound Impression::-
Cholelithiasis
Bilateral grade 1,2 RPD
On 07/07/2022
Serum iron


CBP

Blood grouping


On 08/07/2022
RFT


Hemogram
pallor


Diagnosis
Chronic Kidney disease on MHD with Hypertension and Dm 

Treatment::
On 05/07/2022
Tab. LASIX 40mg/PO
Tab. NODOSIS 500mg /PO
Tab. NICARDIA 20 mg/PO

On 06/07/2022
Tab. LASIX 40 mg/PO/ BD
Tab. SHELCAL -CT /PO/OD
Tab.OROFER  PO/OD
Tab. NODOSIS 500 mg/PO/BD
Tab. NOCARDIA 20mg/PO/BD

On 07/07/2022
Tab. LASIX 40 mg/PO/ BD
Tab. SHELCAL -CT /PO/OD
Tab.OROFER  PO/OD
Tab. NODOSIS 500 mg/PO/BD
Tab. NOCARDIA 20mg/PO/BD
 
On 08/07/2022
Tab. LASIX 40 mg/PO/ BD
Tab. SHELCAL -CT /PO/OD
Tab. NODOSIS 500 mg/PO/BD
Tab. NOCARDIA 20mg/PO/

Comments

Post a Comment

Popular posts from this blog

A 13 yr Male with Redness of eyes,Fever, Burning micturition and swelling of cheeks

Image
A 13yr old male  who is student brought by parents with complaints of Redness of eyes since the 5days Fever since 4days Burning micturition since 4days  History of present Illness: Patient was apparently asymptomatic 5days   back after   which he developed Redness of eyes,followed by Fever which is high grade  insidious onset, gradually progressive associated with burning micturition. H/o yellowish discoloration of eyes 3days H/o swelling in both cheeks since 2days  H/o pain and difficulty in flexing left knee since 2days associated with progressive swelling No H/o recent travel  No H/o  similar complaints in the past  PAST HISTORY  N/k/c/o DM, Hypertension,  TB, Epilepsy,CVD, Asthama,Thyroid disorders PERSONAL HISTORY Single Student Diet :Mixed Appetite: Lost Sleep: adequate Bowel and bladder regular Addictions No  No known Allergies  GENERAL EXAMINATION Pt is conscious coherent and cooperative  Icterus present No...
Read more

CKD with ADPKD

Image
This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss out 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 comprehensing clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitt A 52 yr old male chief complaints  Swelling of Bilateral lower limbs since 1...
Read more

Gm Assignment (Liver Abscess )

Image
Hello all this is G.Chaitanya ,an eighth semester student.This E Log depicts the patient centered approach to learning. This is an online E Logbook recorded to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent. A 32 yr old male came with the complaints of fever since 1 week  HOPI::- Patient was apparently asymptomatic 1 week back and then developed fever which was sudden in onset gradually progressive high grade associated with chills and generalised weakness for which he went to local RMP and took medication for 2 days still the symptoms didnot subside and further investigation like blood test done and his blood sugars were 300mg/dl  As the symptoms didnot subside they went to Miryalguda hospital there USG was done and impression showed HEPATIC ABSCESS  and refered to our hospital  Patient came to hospital yesterday and USG was done impression showing:  NO H/o vomitings  No h/o co...
Read more