GENERAL MEDICINE

General Medicine
21st 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 55yr old male resident of munagoodu, occupation by lorry driver, chief complaint: 
      Puffiness of face since 1 month
      Pedal edema since 1 month. 
     Decreased urine output since a week

History of present illness

Patient was asymptomatic apparently before a month ago, then developed puffiness on face , pedal edema which is started initially in lower limb gradually progressed towards knees. 
 And decreased urine output since a week.
 
History of past illness: 
   Known history of diabetes and hypertension since 15 yrs
 No history of seizures 
  No history of asthma
 No history of tuberculosis
 No history of CVA
 No history thyroid disorders

Personal details: 
  Occupation: lorry driver
  Appetite: normal
  Diet: mixed 
  Bowel: regular
 Micturition: normal
 No known allergies
 
Habits : alcohol consumption.

Family history: not significant.

General examination: 
Built : normal
Consious, coherent and co operative.
Pallor: no
Cyanosis: no
Lymphadenopathy: no
Icterus: no
Clubbing: no
Edema : present
Malnutrition: no
Dehydration: no

Vitals: 
Temperature: 98F
Pulse rate: 88/min
Respiratory rate: 22/min
Bp: 120/80 mmHg

Systemic examination:
  CVS: no cardiac murmurs

  Respiratory: no dyspnea
                        No wheeze
               Position of trachea - central
                
Abdomen : shape - scaphoid
                     No tenderness
No organomegaly

CNS : consious and alert

Provisional diagnosis: 
             Diabetic nephropathy associated with hypertension and end stage renal disease.


             


  
    
 

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