general medicine final practical blog
Welcome and greetings to every one who are visiting my blog.This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.
Chief complaints:
A 60year old male came to OPD with the complaint of decreased urine output since three months,pedal edema and loin(kidney)pain since one month
History of present illness:
Patient was apparently asymptomatic 2 years back,then he developed loin pain since one month which is associated with pruritis.
And bilateral pitting type of pedal edema which is sudden in onset and gradually progressive the edema first starts in the foot then progresses to ankle and then to knee joint which is aggravated on walking or doing any work and relieved on keeping the legs on height and then patient developed shortness of breath since 6 months which is aggravated during sleep after having his meal after a sleep of 2 hrs and then relieved by walking for sometime (grade 2)
No history of fever
No history of palpitations
No history of sweating
No history of PND
History of past Illness:
-known case of diabetes mellitus since 2 yrs
-k/c/o- htn since one month
-n/k/c/o- asthma, epilepsy,cad,tb
Treatment history:
- htn present
-no cad
-no asthma
-no known relevant drug history
-no chemotherapy, radiation ,blood transfusions done.
Personal history:
Married
Appetite normal
Occupation: farmer
Mixed diet
Bowel and bladder: regular
No known relevant allergies
No addictions
Family history:
No other family member has similar complaint
Physical examination:
General examination: -no pallor
-no lymphadenopathy
-no icterus
-no cyanosis
Vitals:
Temp: 97°f
Pulse rate: 79/min
Respiratory rate: 19/min
Bp: 130/90mmHg
Systemic examination:
Cvs: -no thrills
- nocardiac murmurs
Respiratory system: - no dyspnea
-No wheeze
- Breath sounds- vesicular
-position of trachea-central
Abdomen: shape of the abdomen: scaphoid
- no tenderness
- no palpable mass
- hernial orifice normal
-no free fluid
- spleen and liver: not palpable
CNS: level of consciousness - conscious
- Speech : normal
- No neck stiffness and no kernings sign
Provisional diagnosis:
Ckd on mhd.
Plan of care: hemodialysis
Clinical images:
Medication:
Inj. lasix 20mg iv/bd
Tab. Nicardia 20mg po/Tid
Tab. Nodosis 500mg po/bd
Cap.Bio D3 po weekly once
Tab.shelcal 500mg po/od
Tab. Met- xl po/od
Tab orofer XT po/od.
Tab. Metformin
