gm e-log
Hi all, this is Mounika, a 5th sem medical student
This is online E log book to discuss our patients health data shared after taking his guardians informed consent form
I have been given this case to solve in an attempt to understand topic of" patient clinical data analysis" to develop my competency in reading and comprehensing clinical data including history clinical findings investigations and come with a diagnosis and treatment plan. .
A 65 yr old male came to OPD with chief complaints of a Decreased urine output and Abdominal distension
History of present Illness:-
-Decreased urine output, abdominal distension, not associated with pain. Bilateral lower limb swelling which is pitting type since 10 days.
History of low grade intermittent fever not associated with chills, rigors since 10 days.
History of past Illness
K/c/o CKD,4 Cycles of Haemodialysis done
Known case of Hypertension since 2 years and Diabetes since 5 years
Treatment history
Medication used for Diabetes since 5 yrs
Personal History
Diet : mixed
Appetite: losed
Bowel movement: losed
Micturition: Abnormal
Addictions: occasional Alcohol consumption, Smoking
Family history
No relavent family history
General Examination
Patient is conscious,coherent and co operative well oriented with time and place .
Well nourished and built
There are no signs of
Cyanosis
Lymphadenopathy
Clubbing
There is presence of
Pallor
Oedema present 10 days back ,subsided now
VITALS
Temperature: 98.6 degree Fahrenheit
Pulse rate: 86 per min
Respiratory rate: 18 per min
BP: 130/80
SpO2: 96%
Systemic Examination
CVS
S1 S2 heared
No murmurs
RESPIRATORY system
Dyspnoea : no
Wheeze : no
Postion of trachea: central
ABDOMEN
No Tenderness
There is no free fluids
Liver and spleen is not palpable
Bowel sounds are normal
CNS
Conscious with normal'speech
There is no sign of meningeal irritation
Glasgow scale 15/15
Investigations
On 05/07/2022
HBsAg
HIV 1/2 Rapid test
Anti HCV Antibodies
On 07/07/2022
Serum iron
CBP
On 08/07/2022
RFT
hemogram
Diagnosis
CKD with hypertension and DM
Treatment
On 05/07/2022
Tab. LASIX 40mg/PO
Tab. NODOSIS 500mg /PO
Tab. NICARDIA 20 mg/PO
On 06/07/2022
Tab. LASIX 40 mg/PO/ BD
Tab. SHELCAL -CT /PO/OD
Tab.OROFER PO/OD
Tab. NODOSIS 500 mg/PO/BD
Tab. NOCARDIA 20mg/PO/BD
On 07/07/2022
Tab. LASIX 40 mg/PO/ BD
Tab. SHELCAL -CT /PO/OD
Tab.OROFER PO/OD
Tab. NODOSIS 500 mg/PO/BD
Tab. NOCARDIA 20mg/PO/BD
On 08/07/2022
Tab. LASIX 40 mg/PO/ BD
Tab. SHELCAL -CT /PO/OD
Tab. NODOSIS 500 mg/PO/BD
Tab. NOCARDIA 20mg/PO/BD
Comments
Post a Comment