E log

General Medicine case presentation




Vankadoth Saiteja (3rd sem) roll no 143

Dilliswar Veebhuthi , roll no. 145

Under the guidance of Dr.Vamshi  (PG)

This is an online e-log platform to discuss case scenarios of a patient with their guardian's 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, and come up with a diagnosis and treatment plan.

CASE SCENARIO

A 55 yr old patient,(Farmer by occupation) who is a known case of CKD on MHD came with complaints of pedal edema.

Chief complaints

The patient came to the casuality with chief complaints of pedal edema since 3 days.

•HISTORY OF PRESENT ILLNESS

-Patient has oedema since 3 days which is insidious in onset and the oedema is pitting type which is of progressive type.

-No h/o

Burning micturition,decreased urine output,fever,orthopnea PND.

•HISTORY OF PAST ILLNESS

 -Known case of Diabetes Mellitus since 2 yrs.

-Known case of hypertension since 2 yrs.

•PERSONAL HISTORY

-patient is a farmer by occupation has a normal appetite with mixed diet.
-he has normal bowels and micturition.
-has no known allergies.
-non alcoholic.
-non smoker.

•FAMILY HISTORY

-No familial history.

•GENERAL EXAMINATION

-Patient c/c/c well oriented to time,place,person.
-Moderately built,moderate nourishment.

Vitals

-BP:140/90 mm Hg

-PR:96 beats /min.

-RR:15/min.

General examination

-No- pallor/Icterus/cyanosis/clubbing/lymphadenopathy
-Edema of feet:present,pitting type.

•SYSTEMIC EXAMINATION

CVS

No Thrills

*Cardiac Sounds - S1, S2 +

*No cardiac murmurs

RESPIRATORY SYSTEM     

*Dyspnoea - No

*No Wheezing

*Position of Trachea - Central

*Vesicular sounds  

ABDOMEN   

*Shape - scaphoid

*No tenderness, palpable mass.

*No Hernial Orifices.

*Liver, Spleen - Not palpable

*No bowel sounds heard

CENTRAL NERVOUS SYSTEM         

*Level of consciousness - conscious

*Speech - Normal

*Cranial nerves - Normal

*No motor or sensory deficit.

Clinical  Images





Provisional diagnosis

CKD on MHD


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