General medicine

 General medicine

                                      -   125Afrin
                                                                                                             -  3rd sem.

   This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 


 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 a diagnosis and treatment plan.


Case scenario:-

The patient 60yr old male came to casuality with the complaints of shortness of breath,pedal edema, decrease in urine output since seven days.


Cheif complaints:-

The patient came to casuality with the complaints of shortness of breath pedal edema and decrease in urine output since seven days


History of present illness:-

Patient was apparently unsymptomatic 15 days back then developed pedal edema which was gradually progressive associated with sob decrease urine output 

C/oBurning micturition since 15 days

C/o fever since 10 days

No chills and rigor 

No cold and cough

C/o nausea,vomitings,decreased appetite



History of past illeness:-

H/o hypertension 


Personal history:-

Decreased appetite

Decreased sleep

Bowel and bladder regular 

No any addictions 


Family history:-

No h/o same complaints in family.No abnormality detected.


Treatment history:-

No significant treatment history


General examination:-

No pallor, cyanosis,icterus,clubbing,lymphadenopathy

Pedal edema seen

Pulse rate:-110/min

Bp:-130/90mm/hg

Respiratory rate:-18cycles/min

Spo2:98%

GRBS -124 mg%

Systemic examination :-

Cardiovascular system :

No thrills 

Cardiac sounds S1,S2+ 

No cardiac murmurs 

Respiratory system :-

Position of trachea - central 

No dyspnoea, wheezing 

Breath sounds -vesicular 

Abdomen :-

scaphoid

No tender, no palpable mass 

Central nervous system :-

Speech -noraml

No signs of meningeal irritation 

Motor and sensory system - normal 

Reflexs - present 

Cranial nerves - intact 

Investigations :- 





Blood urea - 


Anti HCV Antibodies - RAPID 


Complete blood picture (CBP)  


Blood grouping  and RH Type - 


HBsAg-RAPID-


HIV 1/2 Rapid Test - 



Provisional diagnosis :-

CKD on MHD 

Treatment :- 

* Tab LASIX 40mg PO / BD/ BAM 4pm 

* Tab NICARDIA PO / BD 8Am 

* Tab NODOSIS 500 mg PO/ BD 

* Tab LIVOGEN PO/ BD 

* tab ERYTHROPOIETIN



 


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