Skip to main content

medicine long case



Hall ticket no : 1701006198

This is 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 patients 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 comment box is welcome.

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 diagnosis and treatment plan


Chief complaints:

-Shortness of breath Since 2 days 

-Bilateral pedal edema since 2 days 

-Decreased urine output since 2 days 

Time line of events: 


HISTORY OF PRESENTING ILLNESS:-

Patient was apparently asymptomatic six years back 
Then developed pedal edema  which is bilateral and body pains ,for which she visited hospital and diagnosed with hypertension and renal failure and on conservative management 
2 years back ,  she admitted in hospital for 2 days as she have giddiness and fever 
Recurrent episodes of fever occur which temporarily relieved on medication 
From past 2 days 
—patient developed shortness of breath grade 4  sudden in onset,  not associated with chest pain  ,sweating 
No orthopnea &  cough 
—Bilateral pedal edema   which is pitting type 
—Decreased urinary output not associated with        burning micturition 
-- constipation 

Past history: 

Known case of hypertension since 6years
Known case of chronic kidney disease since 6 years 
diabetes mellitus type -2( diagnosed after coming to our hospital) — GRBS ( random glucose test ) is 418mg% 
Not a known case of Asthma,TB ,CAD, epilepsy 
No history of surgeries in the past
No  history of blood  transfusions.

Personal history:

Diet -mixed 

Appetite -normal

Sleep -adequate 

Bowelmovements-irregular since 2 days 

Bladder movements-decreased urinary output since 2days

No known drug or food allergies 

No addictions

Family history:

No significant family history

General examination: 

After taking consent ,patient is examined in well lit room

Patient is conscious, coherent and cooperative well oriented to time ,place and person 

moderately  built and moderately  nourished 

Pallor- present 

Icterus -absent 

Clubbing -absent

Cyanosis -absent 

Generalised lymphadenopathy -absent 

Edema- present  








VITALS:-

Temperature-afebrile

Pulse rate -106 beats per minute ,regular rhythm ,normal volume,normal character ,no radio radial delay

Blood pressure -160/80mmHg measured in left arm in supine position 

Respiratory rate -34 cycles per minute

SpO2- 92 %at room air 

 Systemic examination:

Respiratory system:

Upper respiratory system - normal

Examination of chest-

Inspection:

Shape of the chest -normal, bilaterally symmetrical

Trachea -central in position 

Respiratory movements -normal, bilaterally symmetrical

No scars,sinuses, engorged veins seen on chest wall

Palpation:

No local rise of temperature

No tenderness 

All inspectory findings are confirmed

Trachea -central in position

vocal Fremitus - normal 

Chest movements - normal ,symmetrical bilaterally

Percussion:

Resonant note heard

Auscultation: 

Bilateral air entry present

Normal vesicular breath sounds heard

Bilateral basal crepitations  heard at infrascapular and infra axillary 


Cardiovascular  system :  

 S1  S2  heard , no added sounds are heard , no murmurs  are heard 

Abdominal examination:

Per abdominal- normal and non tender , no Organomegaly 


Central nervous system examination- 

Higher mental functions -normal
 Cranial nerves-Normal
Sensory and motor examination- normal
Reflexes-normal 

Investigations 

Hemogram: 

10/ 6 / 22

 11/06/22






Ultrasonography - 

Right Grade 3 RPD

Left Grade 2 RPD


ECG : 
10/6/22
11/6/22





PROVISIONAL DIAGNOSIS : 

Chronic renal disease with  pulmonary edema and metabolic acidosis with denovo diabetes mellitus type-2

Treatment:- Dialysis was done after admission in hospital

1)Inj.LASIX 40mg IV/BD

2)tab.NODOSIS 500mg PO/OD

3)tab.MET-XL 25 mg OD

4)tab.AMLONG 10mgOD

5)cap bio-D PO weekly once 

6)tab. SHELCAL 500 mg PO OD

7)inj. Erythropoietin 5000 units weekly once 

8)inj.INSULIN SC according to the GRBS 

9) cremophen syrup




Comments

Post a Comment

Popular posts from this blog

Internship assessment

Intern assessment and extension sample:   Name : Y.Rahul Posted from 4/7/2023 till 4/9/2023 During unit duty :  In Unit postings I have seen cases and done blogs of those cases.  I created the PaJR Groups for those patients and Communicated With patient  Monitored Blood transfusion and KCL infusion For patients Took multiple blood samples Took ABGs from radial artery n femoral, Unit duties mainly consist of OP days, along with looking after casualty cases and overall monitoring and treatment regimens of the patients that get admitted under your care. Ward duties: Improved my history taking abilities  Helped my colleagues in updating SOAP notes. IM/IV Injections collected blood samples attendend rounds   ICU and AMC Duties - monitored the vitals of patients timely ( varying from hourly basis to 2nd hourly) -Inserted Foley’s catheters  -Inserted condom catheter,  -Observed insertion of central line  -Attended rounds for ICU and AMC cases. ...
Read more

190 Rahul.Y

A CASE OF 40 YEAR OLD WITH FEVER AND SOB AND LEFT LL SWELLING since 3 days A came to casuality with c/o fever since 3 days  SOB grade 2----> 4 since 2 days  LL swelling and redness since 1 day. Patient was apparently asymptomatic 3 days back and then he developed fever which was low grade, intermittent, relieved ontaking medication and not associated with chills and rigor. He has SOB, No orthopnea or PND or pedal edema or chest pain or palpitations. He applied ointment for leg pain over right foot and later he developed redness and swelling over right foot and with these complaints they went to outside hospital and on presentation to the outside hospital vitals spO2-74% on RA with BP 70/40. He was put on CPAP and inotrope support and reffered to our hospital General Examination: Patient is C/C/C No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema Vitals: Temp - 100 F PR- 104 bpm BP- 100/70mmHg RR- 28 cpm SpO2- 97% at RA CVS: S1 S2 + RS: Decreased BAE...
Read more