MEDICINE LOG

-103 Pavan


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, come up with a diagnosis and treatment plan.

A 70yr old male came to medicine opd with chief complaints of

-generalised body pains 

-decreased appetite 

-shortness of breath since 10 days

HISTORY OF PRESENTING ILLNESS:-

Patient was apparently asymptomatic 8yr back then he developed stomachache for which he got investigated and diagnosed of having cholelithiasis and found to have chronic kidney disease. for cholelithiasis surgery was done and ckd was managed conservatively. he was fine till january  of 2023 when he started to have vomiting and fever episodes on and off and found to have progression of kidney disease and was advised hemodialysis. He was started on mhd since 2 months and was doing well. patient developed body pains especially in lower back and neck and decreased appetite since 10 days. decreased range of movements, inability to stand from sitting position, swelling of joints, no relieving factors, sob present not associated with cough, palpitations, No h/o decreased urine output; Hematuria absent,pyuria absent, h/o chronic nsaid abuse present,orthopnea pnd absent.

PAST HISTORY:-

K/C/O  DM2 since 20 yr on medication

k/c/o htn since  yrs on medication

TREATMENT HISTORY:-

Diabetes since 20 yr on medication

htn since 8 yr on medication

blood transfusion :3 months back 4 units of blood during dialysis

surgeries: colecystectomy 8yr back

PERSONAL HISTORY:-

Appetite: normal

diet: mixed 

sleep: adequate

bowel and bladder:normal

no addictions

FAMILY HISTORY:-

Not relevant  

GENERAL EXAMINATION:-

Patient is consious,coherent, and cooperative well oriented to time place and person moderately built and nourished 

Pallor - Absent

Icterus - Absent

Cyanosis -  Absent

Clubbing - Absent

Lymphadenopathy - Absent

Pedal edema - Absent









VITALS:-

Tempurature - Afebrile

Pulse- 102bpm

Blood pressure - 140/70 mmhg

Respiratory rate - 26 cpm

SYSTEMIC EXAMINATION:-

CVS- 

Inspection:-

JVP not seen

Auscultation

S1 S2 heard

RESPIRATORY SYSTEM

chest is bilaterally symmetrical 

dyspnoea present grade 2 since 10 days

bilateral airway entry present

trachea - Midline 

no scars

Percussion:-Resonant in nine quadrants

Auscultation- Normal vesicular breath sounds heard

ABDOMINAL EXAMINATION

shape- scaphoid

no tenderness

liver not palpable

spleen not palpable

CNS EXAMINATION

speech normal

no focal neurological deficits seen

INVESTIGATIONS:-







Provisional diagnosis:-

CKD on MDH


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