GENERAL MEDICINE CASE (10/09/23)
GENERAL MEDICINE CASE (11-09-23)
Welcome and greetings to every one who are visiting my blog. This is B.Sravani of 8th semester. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.
DATE OF ADMISSION - 10/09/23
CASE REPORT
A 45 year old female housewife residing in nakrekal came to OPD with chief complaints of 1) swelling in lower limbs since 4days
2) shortness of breath since 4days
3) decreased urine output since 1day
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 4 days back when she developed decresed urine output since 1 days which is insidious in onset and gradually progressive and is associated with bilateral swelling of lower limbs extending up to knee .which is relieved on lying down .H/O shortness of breath while walking since 3 days. C/O fever since 3 days that is relieved on medication .
C/O pain in right and left lumbar region which is nonradiating.
No H/O vomitings ,chestpain ,hematuria .
HISTORY OF PAST ILLNESS:
K/c/o diabetes mellitus since 8 years
K/c/o HTN since 3 days
N/K/C/O TB, Asthma,CVD,CAD,thyroid disorders.
TREATMENT HISTORY:
Glimiperide 2mg
Metformin 850mg
PERSONAL HISTORY:
Married.
Appetite - decreased
Non vegetarian
Bowels- regular.
Micturition- abnormal
Known allergies - none
Habits /addictions :
Alcohol: occasional
Tobacco: smoking ,stopped 7 years back
FAMILY HISTORY :
Nothing significant
PHYSICAL EXAMINATION:
GENERAL:
Pallor is present
No signs of icterus, clubbing of fingers or toes, malnutrition.
Oedema of feet - present
VITALS:
Temp- a febrile
Pulse rate -78bpm
Respiration rate-20 per min
Bp- 150/80mmhg
Spo2: 96
SYSTEMIC EXAMINATION:
CVS: S1S2 ++
No thrills
No murmurs
RESPIRATORY SYSTEM:
Dyspnoea - yes
Wheeze -absent
Position of trachea - central
Breath sounds - vesicular
ABDOMEN :
Shape of abdomen - obese
Tenderness - in right lumbar region and hypochondric region
Palpable mass- no
Hernial orifices - normal
Free fluid - no
Bruits- no
Liver- not palpable
Spleen - not palpable.
Bowel sounds - yes.
CNS:
Level of consciousness- conscious
Speech- normal
Signs of meningeal irritation- none
INVESTIGATIONS:
1) SERUM CREATININE
2) HEMOGRAM
3) BLOOD SUGAR 
4) BLOOD UREA 
5) SERUM IRON 
7) APPT
8) HBsAg -RAPID
9) SERUM ELECROLYTES 
10) PROTHROMBIN TIME
11) BLEEDING AND CLOTTING TIME 
12)BLOOD GROUPING AND RH TYPE 
13) ANTI HCV ANTIBODIES
14) HIV
15) Ultrasound
16)ECG
PROVISIONAL DIAGNOSIS:
Chronic kidney disease secondary to Diabetic nephropathy with k/c/o DM since 8 years .
TREATMENT:
1.Iv fluids NS 30 ml /hr
2. Inj.CEFTRIAXONE 1gm/iv/BD
3. Inj.LASIX 40mg/iv/BD
4. Inj.HAI subcut TID before meals
5.Inj.PAN 40mg/iv/OD
6.Inj.ZOFER 4mg/iv/BD
7. Tab.AMLODIPINE PO/OD
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