GENERAL MEDICINE CASE DISCUSSION.

 29 December 2022

General medicine case discussion

E LOG MEDICINE CASE

29/12/2022

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 comeup with Diagnosis and Treatment plan.

Date of admission: 19 December 2022

A 60year old male resident of Miryalaguda, farmer by occupation came to OPD with chief complaints of swelling in legs since 2 years, lower back pain since 2 months. 

History of present illness:

The patient was apparently asymptomatic 2 years ago then developed pitting type of pedal edema up to his knee joint on both legs then developed lower back pain since 2 months associated with burning micturition. Edema got worsen on walking and it gets when with rest. When he too went to local hospital 3 months ago he was diagnosed with hypertension. He was admitted on 19/12/2022 and dialysis was done 4 times since then. After his 3rd dialysis he developed shortness of breath. 

Past History:

He gave history of trauma of drowning after which he lost his hearing in both ears. 

He is a know case of Diabetes mellitus and Hypertension. 

There is no history of TB, EPILEPSY.

No history of previous surgeries.

Personal History:

Appetite: normal

Diet: Mixed

Bladder habits: regular

Bowel moments: regular

Sleep: adequate

Addictions: Nil

Known Allergies: nil 

Family History:

No significant family history. 

General Examination:

Conscious, coherent, and co-operative. 

Moderately built and nourished. 

Pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing of fingers: absent

Lymphadenopathy: absent

Pedal edema: present- pitting type

Vitals:

Temperature: 98.6 degrees Fahrenheit 

Pulse rate: 82 beats per min

Respiratory rate: 16 cycles per min

BP: 120/80

SPO2: 98%

GRBS: 102mg% 

Systemic Examination:

A. CVS

1. S1 and S2 sounds heard
2. No audible mummers
3. No trills

B. Respiratory system:

1. Dyspnea: absent
2. Position of trachea: center
3. Normal vesicular breath sounds are heard
4. No wheezing. 

C. Per-abdomen:

1. Scaphoid shaped abdomen
2. No visible swellings 
3. No visible scars and injuries
4. No tenderness
5. No palpable mass 
6. Bowel sounds: not heard

D. CNS:

1. Conscious 
2. Speech- normal
3. Signs of meningeal irritation - Nil
4. No neck stiffness
5. No kerming's sign
6. Cranial system - intact 
7. Motor system - intact 
8. Sensory system - intact 
9. Cerebeilar signs: Finger nose- in coordination, Knee heel - in coordination

Investigations:

The following tests were done on 19/12/2022

Provisional Diagnosis: Chronic kidney disease with Diabetic Nephropathy

Treatment: