General medicine

 



General medicine

                                      -   125Afrin
                                      - 103 pavan                                                                           -  3rd sem.

Under the guidance of Dr. Vamshi(pg)

   This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 


 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 comprehending clinical data including, history, clinical findings,investigations,and come up with a diagnosis and treatment plan.


Case scenario:-

The patient 60yr old male who is a known case of CKD on MHD shows a long standing history which goes way back 1 yr back with chief complaints of pedal edema,shortness of breath and decreased urine output.


Chief complaints:-

The patient came to casuality with the complaints of shortness of breath pedal edema and decrease in urine output for seven days


History of present illness:-

Patient was apparently asymptomatic 15 days back then developed pedal edema which was gradually progressive associated with sob decrease urine output 

C/o Burning micturition since 15 days

C/o fever since 10 days

No chills and rigor 

No cold and cough

C/o nausea,vomitings,decreased appetite



History of past illness:-

H/o hypertension 


Personal history:-

Decreased appetite

Decreased sleep

Bowel and bladder regular 

No any addictions 


Family history:-

No h/o same complaints in family.No abnormality detected.


General examination:-

No pallor, cyanosis,icterus,clubbing,generalised lymphadenopathy

Pedal edema present

Pulse rate:-110/min

Bp:-130/90mm/hg

Respiratory rate:-12 cycles/min


Systemic examination :-

Cardiovascular system :-

Cardiac sounds S1,S2+ 

No thrills

No cardiac murmurs 

Respiratory system :-

Position of trachea - central 

No dyspnoea, wheezing 

Breath sounds -vesicular 

Abdomen :-

scaphoid

No tender, no palpable mass 

Central nervous system :-

Speech -normal

No signs of meningeal irritation 

Motor and sensory system - normal 

Reflexes - present 

Cranial nerves - intact 

Investigations :- 





Blood urea - 


Anti HCV Antibodies - RAPID 


Complete blood picture (CBP)  


Blood grouping  and RH Type - 


HBsAg-RAPID-


HIV 1/2 Rapid Test - 



Provisional diagnosis :-

CKD on MHD 

Treatment :- 

* Tab LASIX 40mg PO / BD/ BAM 4pm 

* Tab NICARDIA PO / BD 8Am 

* Tab NODOSIS 500 mg PO/ BD 

* Tab LIVOGEN PO/ BD 

* tab ERYTHROPOIETIN



 

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