General Medicine elog 5

22-06-22
Hi I am Swetha, 3 rd semester student.This is an online elog book to discuss our patient health data after taking his consent.This also reflect my patient centered online learning portfolio.
Chief complaints: A 65 yrs old male patient who was farmer by occupation resident of Nalgonda district came with complaints of SOB, decreased appetite, constipation, burning micturition,and decreased sleep
HOPI: The patient was normal 9 yrs  back ,then developed hypertension ; dailysis was done in August 2021 . Now presented  with  SOB, decreased appetite and sleep since 10 days,backpain non radiating type, constipation since week , burning micturition since week ,fever 4 days ego and yesterday night which was not associated with chills ,rigor.
No history of cough ,cold ,chestpain,
Past illness
Hypertension: since 9 yrs on medication
Seizures: 4 yrs back 
CKD :  8 times dailyasis was done 9 months ago( August ) ,and on medication
Personal history: married, non-vegetarian diet, abnormal micturition, irregular bowels,no known allergies ,
Occasional alcoholic
Smoking
Family history: 
No history of diabetes,HTN,heart disease, stroke,cancer ,TB, asthma
General examination:
Pallor present
No icterus, cyanosis, lymphadenopathy clubbing of fingers and toes, oedema
P.R: 76/min
RR : 24 cpm 
BP: 130/70
Spo2 : 96%
Systemic examination:
CVS : no thrills
Cardiac sounds present
No cardiac murmur
RS: Dyspnea present
Position of trachea central
Breath sounds vesicular
CNS : conscious coherent cooperative 
  Speech : normal
Investigation:
CBP, urea creatinine, electrolytes, CUE,LFT,
Diagnosis : CKD ,CAD, seizures ,HTN
Treatment :
Fllow back 


1 st dialysis : 23-06-22
2 nd dialysis: 25-06-22
3 rd dialysis :28-09-22

Popular posts from this blog

General Medicine eblog

Image
Hi I am Swetha, 6 th semester student.This is an online elog book to discuss our patient health data after taking his consent.This also reflect my patient centered online learning portfolio.  39 F SLE ,ITP since 10 years diabetes since 6 years with generalised weakness since 1 week  History of present illness:        Patient was apparently asymptomatic 1week ago then she developed generalised weakness which is gradually in onset  Past history       known case of SLE since 10 yrs       DM since 6 yrs on medication               Glycomed gp              HCQS 200 mg               Whysirol 5 mg     Not a known case of HTN , asthma, epilepsy, TB, CAD, CVD  Family history:       Irrevalent  Personal history:         Diet : mixed        Appetite: normal        Bowel and bladder movement regular       Sleep : adequate       No addictions  Menstrual history:      Length of cycle : 15 / 30      No of clothes per day : 2       Associate with clots but no pain Vitals : 
Read more

32 year old female came with back pain

Image
June7 ,2022 This is an online e log book to discuss our patient deidentified health data shared after taking her /guardian signed informed consent .here we discuss our individual patient problem through series of input from available global online community of expert with an aim to solve those patient clinical problem with collective current best evident based input    This e log book also reflect my patient centered online learning portfolio and your valuable input on the comment box also welcome   I have been given these 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 , investigation and comeup with diagnosis and treatment plan    Chief complaints A 32 year old female patient ,works in shopping mall by occupation came with complaints of severe back pain since 3 months , vomiting  , TB since 3 months on medication  HOPI Patient was asymptomati
Read more

general Medicine elog 4

Image
21-06-22 Hi ,I am Swetha , 3 rd semester student.This is an online elog book to discuss our patient health data after taking his consent.this also reflect my patient centered online learning portfolio. Chief complaints :   A 37 years old male patient toddy tree climber by occupation resident of Nalgonda district brought to causuality with history of unconscious state since 2 hrs  HOPI : The patient was regular alcoholic,after his routine work as toddy tree climber, around 11am had lunch and went for bringing daily essential and sat in shop aftersome time he started giving money to the people who come to shop it was identified by his wife and  around 4 pm he was feeling uneasy he was shown to RMP doctor and give vit B 12 supplement.and advised for sleep and later on had fruit ( guava)after an hour when his wife was weaking him up for dinner he was not responding brought to hospital.  Past history : alcoholic since 20 years . Varicocele 1 yrs back  Personal history: normal appetite,non v
Read more