General Medicine 


                                                                                                           -   107 sujeeth


                                                                                                                                                                  

   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, come up with a diagnosis and treatment plan.


Date of admission:-15/11/21


Case scenario:-

A 61 year old female patient came with the complaints of swelling in the legs since 3 months, shortness of breath, facial puffiness and decreased urine output since 1 week


Chief complaints:- 

-Pedal edema, pitting type upto thigh

-Facial puffiness 

-Lower limb Reema

-Shortness of breath


History of present illness:-

Patient was apparently asymptomatic 3 months back then developed pedal edema which was gradual onset and slowly progressive associated with shortness of breath on exertion and decreased urine output.

No history of chest pain and palpitations.

No history of burning micturition.

No history of Orthopnea PND.




History of past illness:-

Known case of Chronic Renal Failure.

Haemodialysis done 4 times and failure of follow up on conservative management thereafter.

Known case of Hypertension.



Personal history:-

Marital status-married

Diet-mixed

Appetite-normal

Bowels-regular

Has no known allergies

Alcohol-no

Smoking-since childhood less frequent now



Family history:-

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



General examination:-

Patient c/c/c well oriented to time, place, person.

Moderately built, moderate nourishment.


VITALS

Pulse rate-72 beats/min

Respiratory rate-22/min

BP-120/80 mm/Hg

Temperature-98.1 F



Physical examination-

Pallor-absent

Icterus-absent

Cyanosis-absent

Clubbing of fingers/toes-absent

Generalized Lymphadenopathy-absent

Edema of feet-present, pitting type




Systemic examination:-

CARDIOVASCULAR SYSTEM-

S1 S2 Heard

No thrills

No cardiac murmurs




RESPIRATORY SYSTEM-

Vesicular breath sounds heard

Trachea centrally in position

No wheezing




ABDOMEN-

Scaphoid shaped abdomen

No tenderness

No palpable mass

No hernial orifices

No free fluid

Liver and spleen are not palpable

No bowel sounds heard



CNS-

Conscious and normal speech

Normal gait

Cranial nerves normal

Sensory system normal

Motor system normal



INVESTIGATIONS-




































Clinical images:









Provisional diagnosis:


CKD 


Treatment:

Supportive(maintainence on hemodialysis)


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