SHRUTHI ARUKONDA 02



 GENERAL MEDICINE. 


18 June ,2022.  

Note: This is an online E Log book recorded to discuss and comprehend our patient's  de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.


             CASE REPORT

A 57 year old male with chief complaints of pedal oedema, shortness of breath , and decreased urine output.  

CHEIF COMPLAINTS: 
Pedal Oedema 
Shortness of breath since 10 days.  
Decreased urinary output since 1 week.  


HISTORY OF PRESENT ILLNESS: 



HISTORY OF PAST ILLNESS: 
 Hypertension: since 10 years 
N/k/c/o TB, epilepsy, DM. 

TREATMENT HISTORY: 
Nothing significant 

PERSONAL HISTORY: 
Appetite : decreased 
Vegetarian since one year 
Sleep: 
Alcohol: stopped since one year 
Smoke : stopped bidi since one year 

FAMILY HISTORY : 
Nothing significant 

PHYSICAL EXAMINATION: 

GENERAL EXAMINATION: 
Pallor : seen 
Oedema of feet : seen (pitting). 
No signs of icterus, cyanosis, clubbing of fingers, lymphadenopathy.  

VITALS: 
Temperature : 98.6
Pulse rate : 98
Respiration rate : 
BP: 140/90
sPO2: 90%
GRBS: 98mg% 

SYSTEMIC EXAMINATION : 

CVS: 
Thrills : no 
Cardiac sounds: S1,S2 +
Cardiac murmurs : no 

RESPIRATORY SYSTEM : 
Dyspnoea : 
Wheeze : BAE +.   BASAL EMPTY + 
Position of trachea : central. 

ABDOMEN: 
Shape of abdomen : scaphoid 
Tenderness: not 
Palpable mass: no 
Hernial orifice:Normal 
Free fluid: no 
Bruits: no 
Liver: not palpable 
Spleen: not palpable 
Bowel sounds: yes 

CENTRAL NERVOUS SYSTEM: 
1. Level conscience: conscious 
2. Speech: normal 

INVESTIGATIONS: 

1. Blood grouping and RH type: 


2. CBP: 


3. USG: 


4.ABG: 



5. Blood sugar - random : 


6. LFT. 


7. RFT. 


8. SERUM IRON : 



9. HBsAg- rapid : 


10. CUE : 



11. HIV : 




12. ECG: 

16/06/22: 

18/06/22: 



PROVISIONAL DIAGNOSIS: 
CKD in MHD.  
Hypertension.  





















































































Comments

Post a Comment

Popular posts from this blog

SHRUTHI ARUKONDA 02

           GENERAL MEDICINE ASSIGNMENT                           Shruthi Arukonda 02   (3rd sem)                           Monthly  online assignment   I have been given the following assignment in an attempt to read,  comprehend, analyze, reflect upon and discuss captured patient centered data. This is the link of the questions asked regarding the cases: https://medicinedepartment.blogspot.com/2021/06/medicine-department-paper-for-june-2021.html?m=1 Below are my answers to the Medicine Assignment based on my comprehension of the cases.  QUESTION ONE:  1. PULMONOLOGY CASE:    Case details :  https://amitsharma1996.blogspot.com/2021/05/medicine-assignment-may-2021.html Case review :  https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html            Evolution of symptomatology has been very well explained with a proper timeline for clear understanding.  The mechanism of action has also been depicted well  2.NEUROLOGY CASE:A case details:   https
Read more

SHRUTHI 02

Image
  Date of admission :  A 55 year old male resident of Nalgonda presented to the causality with lower back ache and radiating pain to the left leg  since 3 weeks  HISTORY OF PRESENT ILLNESS : Patient was apparently asymptomatic until 3 weeks ago after which he developed lower back ache which is sudden in onset, non progressive, aggravates on movement, relives on rest.  History of trauma (slip and fall from stairs) 3 weeks ago  The patient was taken to the local hospital where he was found to have L5 burst fracture on CT pelvis.  No history of lifting heavy weights, fever, burning micturition,  PAST HISTORY :  k/c/o DM T2 since last 30 years  K/c/o CAD since 2 years  N/k/c/o of HTN, epilepsy, TB, asthma.  History of  PCTA 2 years ago   TREATMENT HISTORY:  Tab. Metformin 500mg  Tab . Roglibose 0.2mg  Tab. glimidipine 2mg  PERSONAL HISTORY :  sleep : adequate  Bowel and bladder : regular  Appetite : normal  Addictions: alcohol occasionally  Allergies : none  GENERAL EXAMINATION:   Bilatera
Read more

SHRUTHI ARUKONDA 02

      GENERAL MEDICINE            SHRUTHI ARUKONDA 02 ( 3rd sem)          BIMONTHLY ASSIGNMENT- August  I have been given the following assignment in an attempt to read,  comprehend, analyze, reflect upon and discuss captured patient centered data This is the link of the questions asked regarding the cases: https://medicinedepartment.blogspot.com/2021/08/medicine-paper-for-aug-2021-bimonthly.html?m=1 Below are my answers to the Medicine Assignment based on my comprehension of the cases. QUESTION ONE :  Long case:  The history taking was exceptionally good  The exacerbating factors were very well depicted  The details of his joint pains has been explained well.  The general and systemic examination were very explicit.  The various differential diagnosis approach was very depicted along with proper explanations .  Short case:  The history of present illness was taken down exceptionally well  All the alleviating and exacerbating factors were very well mentioned.  The personal history is v
Read more