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 : Krishna Swarali Vavilala
Roll no : 62
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
