General Medicine Case Discussion
December 23, 2022
General medicine case discussion
E LOG MEDICINE CASE
23/12/2022
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 V
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.
CASE DISCUSSION
Date of admission:17/12/2022
A 13 year old female came to opd who is a student came with,
CHIEF COMPLAINTS:
Generalised swelling of body and hematuria since 40 days.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 43 days ago. Later she had fever associated with vomiting and loose stools. After subsiding of fever she developed hematuria and generalized body swelling. Initially she had bilateral pedal edema progressive to abdomen, upper limbs and facial puffiness.
PERSONAL HISTORY:
Appetite: Normal
Diet:Mixed
Bowel and Bladder habits:regular
Addictions: Nill
Allergies: nill
PAST HISTORY:
No history of similar complaints in the past
There is no history of DM,HTN,TB, EPILEPSY.
No history of blood transfusions.
No history of previous surgeries.
FAMILY HISTORY:
No significant family history
GENERAL EXAMINATION:
Conscious, coherent, co-operative
Moderately built,nourished
Pallor: Present
Icterus:absent
Cyanosis:absent
Clubbing of fingera:absent
Lynphadenopathy:absent
Pedal edema:absent
VITALS:
Temperature: 98.4 F
Pulse rate :74 beats /min
Respiratory rate:18 Cycles/min
BP:120/90mm of hg
SPO2:98% at room air
GRBS:92mg%
INVESTIGATIONS:
ECG:
