GENERAL MEDICINE E-LOG
October 21 2021.
GENERAL MEDICINE
-V.VIKRAM
- K.MANIDEEP
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.
Date of admission;20-10-21
Case senario:-
A 27 year old male patient who is known case of CKD on MHD came with chief complaints of pedal edema.
Chief complaints:-
The patient came to casuality with the complaints of shortness of breath and pedal edema since 3 days.
HISTORY OF PRESENT ILLNESS:-
patient was apparently asymptotic one month back then developed pedal edema which was gradually progressive associated with shortness of breath.
No history of burning micturation.
No history of decreased urine output.
No history of orthopnea PND.
No history of fever.
HISTORY OF PAST ILLNESS:-
Known case of hypertension since 2 years
PERSONAL HISTORY:-
DIET: mixed
APETITE: decreased
BOWELS:regular
MICTURATION:normal
HAS NO KNOWN ALLERGIES
NO CONSUMPTION OF ALCOHOL
NON SMOKER
FAMILY HISTORY:-
No history of same complaints in family.no abnormalities detected.
GENERAL EXAMINATION:-
patient c/c/c well oriented to time,place,person.
Moderately built,moderate nourishment.
VITALS:-
Pulse rate: 92 bts/min.
BP: 140/90 mm of Hg
Respiratory rate: 24/ min
Temperature:98.6 F.
PHYSICAL EXAMINATION:-
pallor:absent
Icterus:absent
Cyanosis:absent
Clubbing of fingers/toes:absent
Generalized lymphadenopathy:absent
Edema of feet:present, pitting type.
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM:
S1 S2 heard
No thrills
No cardiac murmors
RESPIRATORY SYSTEM
vehicular breath sounds heard.
Trachea centrally in position
No Wheezing
Dyspnea:present
ABDOMEN
Scaphoid shaped abdomen.
No tenderness
No palpable mass
Normal hernial orifices
No free fluid
Liver and spleen are not palpable
No bowel sounds
CNS
conscious and normal speech
Normal gait
Cranial nerves normal
Motor system normal
INVESTIGATIONS
CLINICAL IMAGES
PROVISIONAL DIAGNOSIS
CKD ON MHD
TREATMENT
on 21-10-21
Tab NICARDIA 20mg PO/TID
Tab OROFER XT PO/BD
Tab ARKAMINE 0.1mg PO/TID
Tab MET XL 50mg PO/OD
Tab LASIX 40mg PO/BD
Tab SHELCAL 500mg PO/OD
Tab PRAZOSIN 5mg PO/RD
Tab TELMA 40 mg PO/ND.
