Gm Case 3

Case scenario: 

Myself K. Pranay Kumarof 3rd bds . This is an online e log book to discuss our patient de-identified health data shared after taking  her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.


This E blog also reflects my patient centered online learning portfolio. 

• Chief Complaint :-

A 67 years old female came to OPD with chief complaints of
-pedal edema since - 3months.
-Shortness of breath since - 3 months
- Decreased urine output since 3 months. 

• History of present illness :-

Patient was apparently asymptomatic 1yr back then she noticed decreased  urine output and was diagnosed to have  heart failure and renal  failure and started on conservative management. 
Then 3months back she noticed increased Bilateral pedal edema -pitting type, extending till ankles . 
shortness of breath - grade 3 insidious onset and progressive.
No history of burning micturition, paroxysmal nocturnal dyspnoea,cough, cold, fever.

• History of past illness :-

K/C/O Hypertension since 30 years, diabetes mellitus since 30 years
Not known case of asthma, tuberculosis, epilepsy.

• Medical history :-

For diabetes Tab Glimy 3mg/PO/BD.
For hypertension tab nicardia , Prolomet XL 50





• Personal history :-

 Diet - Mixed
 Appetite - Lost 
 Sleep - Adequate 
 Bowel and bladder movements- Irregular ( constipation) 
 Micturition - Abnormal
 No addictions.

• Family history:- 

No one of family has similar disease.

• General Examination :-

Patient is co-operative coherent consciousness and well oriented to place and time . 
No pallor, cyanosis, icterus, lymphadenopathy, clubbing of fingers.
Edema - present

• Vitals : -
 Temperature - 98 °F
 Bp - 160/100 mmHg
 Pulse rate - 100 bpm
Respiratory rate - 16 cycles/ min.

• Systemic Examination :-
  
Respiratory system -

Inspection : -

Chest is normal bilaterally symmetrical 
Position of trachea is central 
Movements are bilaterally symmetrical.
No scars , sinuses, or visible pulsations.
Suprasternal and supraclavicular notching is present.

Palpation :

No local rise of temperature
No tenderness
All inspectory findings are confirmed
Apex beat felt in 5th intercostal space 2cm lateral to midclavicular line .

Percussion :-

Resonant sound is heard
Auscultation 
Normal vesicular sounds are heard.

CVS -

Inspection :

Bilaterally symmetrical chest
No visible  engorged veins,scars or sinuses on chest.

Palpation :

S1 S2 are heard
No thrills , no murmurs 
Apex beat present at 5th intercostal space 2cm  lateral to midclavicular line .

Auscultation : 


No cardiac murmurs heard.

Abdomen - 

Obese, inverted umbilicus. 
No visible scars, sinuses, fistulas, engorged veins.
No organomegaly. 
Soft , non tender , no free fluid. 

CNS -

Conscious, speech is normal, no neck stiffness and kernings sign negative.
No finger and nose in coordination.

Provisional diagnosis: - Chronic renal failure 
HFpEF - Right heart failure.(Heart failure with preserved ejection fraction).

Investigations: - 

2D echo -





USG ABDOMEN :-






Complete Urine examination:-



Random Blood Sugar :-


Serum creatinine -


Serum electrolytes -


ECG -




Complete blood picture -







Management:- Hemodialysis

Tab Nodosis 500mg PO/BD
Tab shelcal PO/OD
Tab orofer XT PO/BD
Cap Bio D3 OD
Tab Nicardia 20mg PO/BD
Inj Erythropoietin 4000IU Once weekly





Popular posts from this blog

Gm Case 2

Image
GM case 2        73 year person came with complaints of shortness of breath swelling on his leg and pain in chest and also abdomen since 9 days.     Case Scenario:    My self Kaleru .Pranay Kumar of 3rd BDS .This is an online E log book to discuss our patients de- identified health data shared after taking her guardian's signed informed consent.Here we discuss our individual patients problem through series'of inputs from available global online community of experts with aim to solve those patients clinical problems with collective current best evidence based inputs. I have been given this case to slove in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including history, findings, investigations, diagnosis and treatment plan. Chief complaint: Shortness of breath since 9 days Abdominal and chest pain since 9 days  Pedel edema since 9 days  History of present illness: Patient was asymptomatic
Read more

GM Case 1

Image
March 4, 2023 General medicine Case -1 Case senario.......  Hi I am K.Pranay kumar, 3rd BDS student. This is an online blog Book to discuss our patients health data after taking his consent. This also reflects my patient centered online learning portfolio                            CASE HISTORY Patient details A 35 years old man came to hospital with unable to walk, sweating the legs, tingling sensation History of present  Illness: *Patient was apparently asymmetric 4years back *The  Patient has suddenly unable to walk and he couldn't walk since 4 weeks He was feeling the tingling sensation and sweating all over his legs after he found that he couldn't walk normally *pedal edema present 3 weeks back while coming to hospital now it is absent *legs became weak eventually  *tyroid conformed History of past illness: Tingling is present 4-5year back but it cured through medicines *No Hypertension  *No Diabetes Mellitus *No Tuberculosis *No CAD *No CVA Family history No similar compl
Read more