CKD -GENERAL MEDICINE LONG CASE

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed 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 portfolio and your valuable inputs on 

CHIEF COMPLAINTS
A 60 yrs old male patient farmer by occupation, resident of nalgonda , Presented with the chief Complaint of 
: burning micturition and less amount of urine outflow since 4 month, pedal edema since 2months
:shortness breath  since 2 months

HISTORY OF PRESENT ILLNESS 
Patient was apparantly asymptomatic 4 months back and  then he  experienced pain during micturition, less urine out put and pedal edema since 2 months(pitting type extended from below knee ,lower part of limb, it is decreased after dialysis now resolved)
SOB: grade 3, insidious onset gradually progressed and relieved on laying down, diurnal variation is seen, more at night time not associated with fever, cough and cold 

HISTORY OF PAST ILLNESS 
.History of DIABETES MELLITUS   since 10years and he is on medication (glimepiride)
.History of BACKPAIN since 6 years and he is on medication (ibuprofen)
.History of  HYPERTENSION  SINCE 3 months (Amlodipine)(nifedipine)
.Partial DEAFNESS SINCE 20 YEARS
 No H/o chest pain, chest tightness.
    Not a known case of Epilepsy, CAD, Asthma.

PERSONAL HISTORY 
Daily routine of a patient  before developing pedal edema
He is farmer by occupation,  he wakes up at 6am in the morning and he used do work till 9 am and takes breakfast at 9 am after he went for agriculture field, he does take lunch lat afternoon times and later at 4pm he take lunch , dinner at 7pm after at 8.30 pm he sleeps
Married
  Farmer by occupation
  Appetite: decreased since 1month
  Diet: Mixed
Sleep :Inadequate since 2months
  Bowel and bladder movements:regular 
  Micturition: Abnormal
  Alcohol: occasionally
Family history 
 NO RELEVANT FAMILY HISTORY 

GENERAL EXAMINATION 

Vitals: 
Temp: 98°F
Respiratory rate: 28cycles/min
Pulse: 88beats/min
Blood pressure: 130/70mmHg
Sp O2 98%
GRBS: 138mg%

Systemic examination ;
By taking the consent from patient examined in a well ventilated room

Cardiac Examination 
Thrills: No
Cardiac sounds: S1, S2 positive

Inspection:-
Bilaterally symmetrical chest
No visible engorged veins,scars or sinuses on chest.

Palpation:-
S1 S2 are heard
No thrills , no murmurs 

Auscultation:-
Cardiac rate - 88 beats per minute 
No cardiac murmurs heard

Respiratory system 
Position of trachea: Central 
Breath sounds: decreased breath sounds at right IAA and ISA
Dysponea:present

 Inspection 
Chest appears Bilaterally symmetrical & elliptical in shape
Respiratory movements normal
No signs of volume loss
No dilated veins, scars, sinuses, visible pulsations. 
No rib crowding ,no accessory muscle usage, no drooping of shoulder.

Palpation :-
All inspectory findings are confirmed
Trachea is in central position 
Chest movements-symmetric 

Abdominal examination 
Inspection
Shape of the abdomen- scaphoid
Flanks: flanks are free
Umbilicus- central and inverted.
no visible sinuses and scars are seen.
No engorged veins 

Palpation:
No local rise of temperature 
No tenderness 
No palpable mass
No organomegaly.

Percussion:
No Fluid thrill
No shifting dullness

Auscultation:
Bowel sounds are heard.
CENTRAL NERVOUS SYSTEM 
Patient is conscious, coherent, cooperatively well oriented to time and place.
Speech: Normal
Sign of Meningitis: No
ORAL EXAMINATION  FINDINGS 
Loss of maxillary anterior tooth
Mobility of teeth is seen in lateral tooth
Patient complaints of dryness of mouth

DIALYSIS DATA 
CURRENTLY  patient is on dailysis 
Totally 10 times dialysis occurred to that patient
On progression of dialysis blood pressure is decreased 

PROVISIONAL DIAGNOSIS 
CHRONIC KIDNEY DISEASE WITH DIABETIC NEPHROPATHY 

INVESTIGATIONS 
COMPLETE URINE EXAMINATION 
RENAL FUNCTION TEST
HEMOGRAM
 SERUM ELECTROLYTES 
Serum Creatinine levels

RANDOM BLOOD SUGAR:

ECG
2D ECHO FINDINGS  





Oral examination 



previous hospital reports
TREATMENT :

Tab.Nodosis 500mg BD
Tab Lasix 20mg BD
Tab.Nicardia 20mg TID
Cap.Bio D3 once weekly
Tab Shelcal 500mg OD
Tab Orofer XT OD
Tab Ecospirin 75mg H/s











Comments

Post a Comment

Popular posts from this blog

DENGUE FEVER

Image
This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from  available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input. This E-blog also reflects my patient's centred online learning portfolio. 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. 60 year old female came to casualty with chief complaints of fever since 10 days and Back pain since 20days .HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic 20 days back then she developed backpain which is dragging and aggravated onsitting and relieved on medicat
Read more

GENERAL MEDICINE

Image
This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from  available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input. This E-blog also reflects my patient's centred online learning portfolio. 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  1. COMPLAINTS AND DURATION *p atient complaints  of Tingling and numbness I week of both UL And LL  *Generalised weakness and body pains. I -week. * decreased Tactile of LL. I-month 2. HISTORY OF PRESENT ILLNESS  patient was apparantly assymptomentomatic I week back, and later he deve
Read more

LAPROSCOPIC CHOLECYSTECTOMY

Image
9/3/2022   This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed 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.. A 36 year old Female who is farmer by occupation came to the Casuality with ABDOMINAL PAIN. HISTORY OF PRESENT ILLNESS: Normal routine of the patient: She used to get up at 6 a.m in the morning, used to have tea and did some household work, then breakfast at 8 a.m(rice) then used to go for farming, he used to have lunch at 2 which is rice again. She used to return home by 6 in the evening then he used to freshen up and have dinner at 8 PM and sleep after that The Patient was apparently asymptomatic 3months back then developed pain in right hypochondrium on/off.. She went to a local doctor, sympto
Read more