GENERAL MEDICINE

Hi, Iam Supriya 5th sem medical student. This is an online elog book to discuss our patients health data shared after taking his/her/guardians consent. This also reflects patient centered care and online learning portfolio. This E-log book reflects my patient -centered online learning portfolio. 

A 68year old female resident of chityala came to the casuality with chief complaints of 

-Dysuria
-Burning of Micturition

HISTORY OF PRESENT ILLNESS
 
      Patient was apparently asymptomatic before     2011.In 2011,she visited hospital with chief complaint of dysuria. Upon biochemical investigations, her serum creatinine level was high i.e., 2.0.
  In 2012 to 2018,she has diagnosed with occasional recurrent UTI/pyuria due to the presence of pus in urine on investigations. 
 On 21/5/22, she went to the hospital with chief complaint of leg swelling, decreased appetite, nausea and vomiting. She has diagnosed with CKD V, UTI, UROSEPSIS WITH ANEMIA. She underwent 4hemodialysis and AV FISTULA 15 days back and 2hemodialysis in kamineni. 

HISTORY OF PAST ILLNESS

Not a known case of DM/HTN/THYROID, CAD, CVD, TB, EPILEPSY. 
known case of osteoarthritis. 
Known case of CKD on medical management

PERSONAL HISTORY
Married
Mixed diet
Appetite -decreased
Micturition-dysuria
Bowel habits -regular
No addictions 

FAMILY HISTORY

No significant family history

MENSTRUAL HISTORY

Age of menarche-14 years

OBSTETRIC HISTORY

Age of marriage-21 years
Age of first child birth-22years
Gravida -4
Still birth-1

PHYSICAL EXAMINATION
A. General examination-patient was conscious. Responding When calls with different sounds. 
 
Pallor-present
Icterus -absent
Cyanosis-absent
Lymphadenopathy-absent
Oedema-present Grade 2 pedal edema
Malnutrition -absent
Dehydration-absent

VITALS

Temperature-
Pulse rate-126/min
Respiration rate-22/min
BP-180/90mmhg
Spo2 at room air -98%

B. Systemic examination
CARDIOVASCULAR SYSTEM
Thrills -No
Cardiac sounds -s1, s2 present
Cardiac murmers-absent

RESPIRATORY SYSTEM
Dyspnoea -No
Wheeze-no
Position of trachea-central
Breathe sounds -vesicular
Adventitious sounds-No

ABDOMEN
No tenderness
No palpable mass
Normal hernial orifices
Free fluid -No
Bruits-No
Liver-non palpable
Spleen-non palpable
Presence of bowel sounds

CENTRAL NERVOUS SYSTEM
consciousness
Speech-normal
Signs of Meningeal irritation-absent
Cranial nerves, motor and sensory system- intact
Glasgow scale-15/15

REFLEXES
Present
Plantor flexion bilaterally

CEREBRAL SIGNS
Absent

GAIT-Normal

INVESTIGATIONS
ECG
Hemogram
Haemoglobin-8.9gm/dl
TLC-6450
N/L/E/M/B-70/10/1/4/0

ABG
PH-7.50
PCo2-31.7
P02-141
Hco3-24.6

RFT
Urea-84
Creatinine-4.1
Uric acid-4.3
Calcium-9.5
P04--
Na+-142
K+-3.6
Chloride-102

PROVISIONAL DIAGNOSIS
CKD on MHD











Comments

Post a Comment

Popular posts from this blog

BIMONTHLY BLENDED ASSESSMENT - JUNE 2021

NAME:G.SUPRIYA REDDY ROLL NO:42  Question 1: Competency tested for Peer to peer review and assessment : Please go through one particular answer of ten students in this link:  https://generalmedicinedepartment.blogspot.com/2021/06/bimonthly-formative-and-summative_19.html?m=1 and share your peer review of each answer with your quantitative marking input as well as qualitative insights into what was good or bad about the answer.  1 PULMONOGY   REVIEW: https://akash688.blogspot.com/2021/05/online-blended-bimonthly-assessmentmay.html   CASE:https://soumyanadella128eloggm.blogspot.com/2021/05/55-year-old-female-with-shortness-of.html   This is a case of Acute exacerbation of COPD associated with right heart failure and bronchiectasis.She is presented with shortness of breathe,genaralised weakness,facial puffiness,drowsiness and decreased urine output.She is a known case of Diabetes Mellitus for the past 8 years.She is a known case of Hypertension.The treatment for all the symptoms has gi
Read more

General medicine case discussion

Image
 G. Supriya reddy 42 67 year old male, sarpanch by occupation resident of nalgonda came with chief complaints of  cough since 1month and  breathlessness since 1month. HISTORY OF PRESENT ILLNESS Patient was apparently normal 1month back. Later he developed shortness of breath since 1 month. Increased on lying down, exertion, decreased on sitting position, taking rest. History of wheeze, cough since 1month with expectoration, mucoid, non foul smelling, No diurnal or postural variation, h/o decreased urine output since 1week.H/o pedal edema since 1week . Loss of appetite, no loss of weight. H/o chest pain, abdominal distension, Tendernrss, pain and fever.  HISTORY OF PAST ILLNESS H/o similar complaints  in past since 2years. Not a known case of Hypertension, diabetes mellitus, CAD.  No history of TB or covid 19 PERSONAL HISTORY APPETITE-Normal Mixed diet BOWELS-Regular MICTURITION-Decreased urine output since 1week ADDICTIONS-Occasional alcoholic, beedi 40/day FAMILY HISTORY No family his
Read more

GENERAL MEDICINE E-LOG

Image
  42  SUPRIYA GAGIREDDY 3rd sem Under the guidance of deepika mam INTRODUCTION : CASE HISTORY AND CLINICAL FINDINGS : 19 year female came to casuality with chief complaints of  2-3 episodes of vomitings ,which is non projectile .Non bilious associated with food particles.5 days back high grade fever.Intermittent ,relieved on medication. Fever subsided 1 day back. HISTORY OF PRESENT ILLNESS : No H/o cold,cough,SOB,Headache Pain abdomen,loose stools Hematuria,Malena,Rash No other complaints PAST ILLNESS : No H/O DM,HTN,ASTHMA,EPILEPSY,CAD,TB PERSONAL HISTORY : No significant personal history FAMILY HISTORY : No significant history GENERAL EXAMINATION VITALS : TEMPERATURE:AFEBRILE PR:96BPM RR:18CPM BP:100/70MMHG SPO2:98%AT RA GRBS:150MG/DL SYSTEMIC EXAMINATION : CVS :S1,S2 HEARD RESPIRATORY SYSTEM :BAE+ NVBS HEARD PER ABDOMEN :SOFT' NON TENDER CNS :NFND INVESTIGATIONS : ECG-NO SIGNIFICANT CHANGES HEMOGRAM:1/8/2021 HB12.77GM TLC4300 CELLS/CU MM PLATELETS:54000CELLS /CU MM RBC:NORMOCYTI
Read more