GENERAL MEDICINE

July 15,2023.

General Medicine.

Case scenario,
 Hi, I am Aishwarya, 3rd bds student. This is an online elog book to discuss our patient health, data after taking his consent. This also reflects my patient centered online learning portfolio. 

                Case history

Patient details
     A 62 yr old male saree weaver by occupation presented with,
 Chief complaints
       Pedal edema since 6 months,
        Decreased urine out put since 1 month
       Vomitings since 15 days
       Shortness of breath since 2 days

History of present illness
        Patient was apparently asymptomatic 10 months back, then he started developing low sugar levels, he visited a local and then sent to a test and diagnosed as renal failure and treated accordingly. 
       Since last 1 month he complaints of decreased urine output, and vomitings since 15 days which is non projectile, non bilious, food particles as content, non blood tinged.
  Also complaints of shortness of breath since 2 days, grade 2, relieved by rest also has a facial puffiness since a week.

History of past illness
       15 yrs back he was diagnosed as diabetes mellitus type 2 and on medication.
      Hypertension since 3 yrs
       Tuberculosis since 5 yrs
      Also diagnosed with CKD since 1 yr
No asthma
No CVA
No epilepsy 

Personal history
        Appetite decreased
        Diet mixed 
        Sleep nrml
        Bowels decreased
        Micturition decreased
        
Habits. 
Alcohol consumption but stopped 5 yrs back
No history smoking. 

Family history.
     Not significant


General examination

Pt. Is consious , coherent and co operative
Pallor : present
Icterus : no
Clubbing: no 
Lymphadenopathy: no
Cyanosis: no
Pedal edema : present

Drug history: 
Amlodipine 10mg 
OHA medication.

Systemic examination: 
Abdomen: soft and non tender
CVS: no murmurs 
Respiratory system: normal


Vitals: 
 Pt. Is consious
Temperature: 96.8F
Respiratory rate: 20cpm
Pulse rate : 80 bpm
Blood pressure: 170/80 mmHg
SpO2: 90

Provisional diagnosis: 
AKI on CKD


        

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