General Medicine Case Discussion

 General medicine case discussion

E LOG MEDICINE CASE

19/12/2022

This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed consent.Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence-based inputs.This e-log book also reflects my patient centered online learning protfolio and your valuable inputs on comment box is welcome.

Name : Mamatha 

Roll no : 65

2020 Batch

I''ve 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 comeup with Diagnosis and Treatment plan General medicine case discussion

CASE DISCUSSION:

Date of admission:17/12/2021

A 45 year old female came to opd who is a farmer came with ,

CHEIF COMPLAINTS:

Lower back ache since 2 months.

 

HISTORY OF PRESENTING ILLNESS:

Patient came with back ache since 2 months associated with pitting edema with pain , exertional dyspnea. Pain got relived on sleeping. She has productive cough since four days. 

PAST HISTORY : 

Known case of hypertension since 2 months. 

There is no history of DM,TB, EPILEPSY.

No history of blood transfusions. 

No history of previous surgeries. 

PERSONAL HISTORY:

Appetite : Normal appetite 

Diet : Mixed 

Bowel and bladder movements : Regular 

Sleep : Decreased sleep since 2 months 

Addictions: None 

 

FAMILY HISTORY:

Insignificant 

GENERAL EXAMINATION:

Conscious, coherent, co-operative

Moderately built,nourished

PALLOR: Present 

ICTERUS: Absent 

CYANOSIS: Absent 

CLUBBING OF FINGERS/TOES: Absent 

LYMPHADENOPATHY: Absent 

PEDAL EDEMA: Pitting edema is present. 

INVESTIGATIONS :

16/12/2022

COMPLETE URINE ANALYSIS :

16/12/2022

COMPLETE BLOOD PICTURE 

17/12/2022

LFT:

16/12/2022

BLOOD UREA :

16/12/2022

SERUM CREATININE :

16/12/2022

RBS:

PROVISIONAL DIAGNOSIS :

CHRONIC RENAL FAILURE (secondary to NSAID abuse) with hypertension. 

TREATMENT :

On 19/12/2022, 

Tab. Nodosis 500 mg  PO BD

Tab. Lasix 40 mg PO BD 

Tab. Orofer XT PO OD 

Tab. Shelcal PO OD

Cap. Bio D3 PO OD

Tab. Nicardia 10 mg PO TID 

Inj. Epo 4000 IU SC weekly once 

Inj. Iron sucrose 100 mg + 100 ml NS weekly once. 

Syrup Ascoryl -LS 10 ml PO TID 

Dialysis is given.