E LOG MEDICINE CASE
01/10/2021.
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Name : Kodati Tejarshini
Roll no : 61
2017 Batch
I''ve 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 comeup with Diagnosis and Treatment plan.
CASE DISCUSSION:
Date of admission:30/09/2021
A 49 Year old female who works in municipality came to the hospital on 30/09/2021 with,
CHEIF COMPLAINTS :
Shortness of breath since 2 days present even at rest(worsening).
Pedal edema since 2 days.
Puffiness of face since 2 days.
History of episode of fever since 2 days.
Complaint of Decreased urine output : Yesterday night
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 5-6 months back,then she developed puffiness of face,pedal edema upto the ankle , which is pitting type .
She also had history of shortness of breath on exertion since 5-6 months.
Now the symptoms got exacerbated since 2days with history of shortness of breath which is present even at rest (grade +4),
Pedal edema which is bilateral ,non pitting type extending upto knees,
History of fever since 2days which is low grade , intermittent,not associated with chills and rigors,there is a history of evening rise of temperature,which get relieved on medication.
There is no associated rashes.
There is no history of burning micturition,polyuria, increased frequency of micturition, urinary incontinence.
No history of cough, palpitations,headache,nausea , vomiting, fatigue,weakness.
PAST HISTORY:
She has similar complaints in the past
She is a known case of Hypertensive since 1 Year and she is on medication but she takes irregularly.
Known case of kidney disease since 5-6 years and not on medication.
There is no history of DM,TB, Asthma,
No history of previous surgeries.
No history of blood transfusions.
PERSONAL HISTORY:
Appetite:Normal
Diet: Mixed
Sleep: Adequate
Bowels:Regular
Micturition:Normal
Addictions:No
FAMILY HISTORY:
Insignificant family history
GENERAL EXAMINATION:
Patient is conscious, coherent, co-operative.
Moderately built,nourished .
FAMILY HISTORY:
Insignificant family history
GENERAL EXAMINATION:
Patient is Conscious, Cohererent, Co-operative.
Moderately built, nourished.
Mild dehydration.
PALLOR: PRESENT
ICTERUS:ABSENT
CYANOSIS: ABSENT
CLUBBING OF FINGERS/TOES: ABSENT
LYMPHADENOPATHY: ABSENT
PEDAL EDEMA: ABSENT.
VITALS:
TEMPERATURE: 98.6 F
PULSE RATE:112Beats /min
RESPIRATORY RATE:28 Cycles/min
BP:170/110mm of hg
SPO2:82% at 100 litres of O2
GRBS:187Mg%.
SYSTEMIC EXAMINATION:
CVS:
S1,S2 Sounds heard,
No audible murmurs,
Thrills:No.
RESPIRATORY SYSTEM:
Dyspnea is present,
Wheeze: Present on expiration,
Position of trachea:central,
Normal vesicular breath sounds are heard,
adventitious sounds like rhonchi,Rales(crepitations) present on inspiration all over lung fields.
ABDOMEN:
Shape: Scaphoid,
Soft and non tender abdomen,
Palpable mass: Absent,
Hernial orifices: Normal,
Free fluid:No,
Bruits:No,
No organomegaly,
Bowel sounds heard.
CNS:
Conscious ,coherent ,co-operative,
No Signs of meningeal irritation ,
Higher mental functions: Intact,
Reflexes: present.
PROVISIONAL DIAGNOSIS:
CKD (Stage-4)
HFrEF secondary to CAD (EF=35%) WITH CARDIOGENIC PULMONARY EDEMA WITH KNOWN CASE OF HYPERTENSION.
PLANNING FOR HEMODIALYSIS.
INVESTIGATIONS:
On 30/09/2021
ABG:
HEMOGRAM:
ULTRASOUND REPORT:
30/09/2021:
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