GENERAL MEDICINE CASE DISCUSSION.

 28 December 2022

General medicine case discussion

E LOG MEDICINE CASE

28/12/2022

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: Kondakindi Vrithika Reddy

Roll no : 59

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 come up with Diagnosis and Treatment plan.

 

A 42 year old female patient who is housewife and does household chores came  to general medicine opd with chief complaints of pedal edema.

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic one month back. Then she noticed pedal edema, vomiting and visited local hospital and serum creatinine level observed is 4.5mg/dl. 15 days back she went to local hospital again as the symptoms are not reduced. Then she was referred to hospital in  Hyderabad.There they observed serum creatinine level raised to 14.4mg/dl, then she was suggested to start dialysis. 

One sitting of dialysis done on 22/12/22.

On 23/12/22  AV fistula surgery for dialysis is done.

Then again on next day i.e 24/12/22 another sitting of dialysis done .

They visited this hospital on 27/12/22 for dialysis.

PAST HISTORY 

4 years back patient developed weakness and fainted. 

So she visited hospital and there they observed serum creatinine level raised to 3.4mg/dl along with increased blood pressure.

Not a known case of Diabetes.

No TB,epilepsy,asthma,CAD

FAMILY HISTORY - no relevant family history

PERSONAL HISTORY

Diet- mixed

Appetite - normal

Bladder and Bowel movement - regular

Sleep -adequate

No history of addictions

ALLERGIC HISTORY - No known allergies

DRUG HISTORY

She is on regular medication with 

Nodosis- 50mg

Mega-3

Metol AM 50 for hypertension.

PHYSICAL EXAMINATION

GENERAL EXAMINATION

Patient is conscious, coherent, comfortable and co-operative

Moderately built, moderately nourished

No pallor 

No icterus

No general lymphadenopathy

No clubbing of fingers 

No Pedal edema

VITAL SIGNS-

Temperature: 98.6F

Pulse:70bpm

BP: 160/80mm of hg 

Respiratory rate: 14cpm

SpO2: 98 percent

GRBS-110mg%

SYSTEMIC EXAMINATION

CVS:

Cardiac sounds: S1 and S2

No thrills

No cardiac murmurs

RESPIRATORY SYSTEM:

No dyspnea

No wheeze

Central location of trachea

Vesicular breath sounds

ABDOMEN-

Abdomen is scaphoid

No tenderness

No palpable mass

Non palpable liver and spleen

Bowel sounds are not heard

CENTRAL NERVOUS SYSTEM 

Conscious 

Speech- normal

Signs of meningeal irritation - 

      no neck stiffness

Cranial system - intact 

Motor system - intact 

Sensory system - intact 

 Cerebeilar signs

    Finger nose- in coordination

    Knee heel - in coordination

PROVISIONAL DIAGNOSIS: Acute kidney disease.