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


        

Comments

Post a Comment

Popular posts from this blog

GENERAL MEDICINE

Image
GENERAL MEDICINE  GM CASE 2 Saturday, March 4th 2023 March 4th 2023 CASE Scenario..... Hi ,I am S.Aishwarya, 3rd bds student.This is an online elog book to discuss our patient health data after taking her consent. This also reflects my patient centered online learning portfolio.                                          CASE HISTORY Patient details A 65 years old female occupation by farmer Resident of Rammanpet presented with the Chief complaint of Pain near the chest region since 3 days and shortness of breathe since 3 days. History of present illness Patient was apparently Asymptomatic 10 days back and then had severe pain in left  loin region which is radiated towards chest region and aggrievated while doing farming work. History Past illness  15 years back ,she noticed a swelling over the right foot and went to hospital then she was diagnosed with type 2 diabetes mellitus and from then she was on regular oral hypoglycemic medication [OHA]. No hypertension No asthma No tuberculosis
Read more

GENERAL MEDICINE

Image
General Medicine August 5th, 2023 Case scenario.     Hi, I'm aishwarya.s 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 63 year old male occupation by farmer , presented with the Chief complaints:    Neck pain, back pain, knee pain, since 6 months.  History of present illness:      Patient was apparently asymptomatic 6 months ago then he had neck pain which is non radiating and there is no restriction of movements. And also complains of back ache since 6 months which is radiating to both the lower limbs and has tingling sensation. Also complains of knee pain from 6 months. History of past illness:         No know history of diabetes mellitus,  Hypertension, epilepsy, tuberculosis, asthma, and thyroid disorders and no CVA. Personal history:   Occupation: farmer   Appetite: normal    Diet : mixed    Sleep : Normal   Mic
Read more

GENERAL MEDICINE

Image
General medicine 19th August, 2023 Case scenario,       Hi I'm 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 57 year old male occupation by farmer, presented with the cheif complaints of pedal edema since 10 days and shortness of breath since 5 days. History of present illness:       Patient was apparently asymptomatic 1 month ago, then felt weakness and after regular checkup he was diagnosed with deranged renal parameter. since 10 days he had pedal edema which is pitting type upto knee.   Also complains of shortness of breath since 5 days [grade 2 gradually progressive] . Decreased urine output since 5 days.  History of past illness:     Known complaint of hypertension since 2 months. Diabetes: no CVA: no Epilepsy: no Asthma : no Tuberculosis: no Thyroid disorders: no Personal history:     Occupation: fa
Read more