General medicine case discussion
E LOG MEDICINE CASE
19/12/2022
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 : kavya dharshini.s
Roll no : 58
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:17/12/2022
A 45 year old female came to opd who is a farmer came with ,
CHEIF COMPLAINTS:
Of painful pedal edema and for dialysis
HISTORY OF PRESENTING ILLNESS:
Patient came with pedal edema since 2 months associated with pain , exertional dyspnea. Pain got relived on sleeping. She has productive cough since four days.she had RF since 5months and came for dialysis
PAST HISTORY : patient was apparently asymptomatic since 2months and developed back ache associted with non pitting pedal edema and diagnosed with RF with HTN in local hospital in miryalguda.
There is no history of DM,TB, EPILEPSY.
No history of blood transfusions.
No history of previous surgeries.
Took pain killers from local RMPs but pain doesn't get relieved
PERSONAL HISTORY:
Appetite : Normal appetite
Diet : Mixed
Bowel and bladder movements : Regular
Sleep : Decreased sleep since 2 months
Addictions: she took alcohol 30 days back
FAMILY HISTORY:
Insignificant
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.
Temperature: afebrile
Pulse rate : 99 bpm
Respiratory rate: 33 cycles / min
BP: 145/ 90
SPO2: 96%
GPRS: 1mg%
BS PRESENT
BAE present
SYSTEMIC EXAMINATION
CVS:
s1 s2 sounds heard;
No audible murmurs; no thrills
RESPIRATORY SYSTEM
Dyspnea present ;
Position of tracha: central
No vesicular abnormal sounds
INVESTIGATIONS :
16/12/2022
COMPLETE URINE ANALYSIS :
Albumin + ; acidic urine
16/12/2022
COMPLETE BLOOD PICTURE
Hb decreased and eosinophilia
17/12/2022
LFT:
AST ; ALT are normal ALP INCREASED
16/12/2022
BLOOD UREA :
BLOOD UREA LEVELS INCREASED
16/12/2022
SERUM CREATININE :
INCREASED
16/12/2022
RBS:
NORMAL
PROVISIONAL DIAGNOSIS :
CHRONIC RENAL FAILURE (secondary to NSAID abuse) with hypertension.
TREATMENT :
On 19/12/2022,
Tab. Enalapril PO BD
Tab. Nodosis 500 mg PO BD
Tab. Lasix 40 mg PO BD
Tab. Orofer XT PO OD
Tab. Shelcal PO OD
Cap. Bio D3 PO OD
Tab. Nicardia 10 mg PO TID
Inj. Epo 4000 IU SC weekly once
Inj. Iron sucrose 100 mg + 100 ml NS weekly once.
Syrup Ascoryl -LS 10 ml PO TID
Comments