E-LOG MEDICINE

GENERAL MEDICINE


                                                         -108 Koushik



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.


Chief complaints:

A 70 yr old female came to OPD with chief complaints of shortness of breath from 10 days ,fever from 10 days,loss of appetite from 6 days ,burning micturition from 4 days,decreased urine output from 4 days.

History of presenting illness:

Patient was apperantly asymptomatic 10 days back then she had SOB grade 4 and fever which is intermittent associated with rigors and chills and relieved on medication.

Patient was taken to hospital 8 days back and diagnosed as typhoid and was treated for the same.

Patient c/o of burning micturition and decreased urine output 4 days back.


History of past illness:

K/c/o dm from 15 years (treatment with metformin 500mg)

K/c/o HTN from 10 years (treatment with telmisartan 40/12.5mg)

N/k/c/o of TB,cad, epilepsy,asthma.


Daily routine:

She wakes up at 5 am 

She does her breakfast at 8 to9 am.daily roti.

She does her household work .

She has lunch at 1.30 pm roti or rice .

She takes rest ,

She takes her dinner around 8 pm .

She sleeps daily at 9 pm.


Family history:

No significant family history.


Personal history:

Appetite normal.

Mixed diet.

Regular bladder and bowel movements.

No allergies .

Addictions:

Alcohol taken occasionally

Tobacco smoking daily 3 times  since childhood.


General examination:

Patient is c/c/c well oriented to time and place .

BP:110/80mm hg.

PR:98bpm

RR:16cpm

No pallor/icterus /cyanosis/clubbing/lymphadenopathy/


Pedal odema present which is pitting type

Abdominal swelling also present .




Systemic examination:

Cvs:

S1,s2heard.
No thrills and cardiac murmurs

Respiratory system:

Dyspnea:present
No wheezing
Position of trachea central
Breath sounds vescicular
BAE +ve

Per abdomen :

Soft ,non tender,swollen
No palpable mass 
Liver and spleen not palpable.

CNS :
 nad

Investigations:










Provisional diagnosis: CKD.


Treatment:

Inj .piptaz 2.25 mg iv/tid
Inj neomal 1 mg iv/sos(if temp >101°F)
Tab lasix 40 mg po/bd
Tab nodosis 500 mg po
Tab orofer -xt po/od
Tab shelcal 500 mg po /od
Tab pcm 500 mg po/sos
Capsule bio D3 po/ weekly twice .


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