GENERAL MEDICINE

This  is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed 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 patient's clinical problems with collective current best evidence-based inputs.This e-log book also reflects my patient centered online learning protfolio and your valuable inputs on comment box is welcome.

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.

Name : J.Poojitha

Roll no : 52

CASE PRESENTATION:

A 60 year old male came to general medicine OPD with complaints of

 loss of apetite since 4 months,vomitings since 4 months,fever  since 1 month and

 lower back pain.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 4months back.Later he developed fever with loss of appetite and vomitings with food particles from 3 months.He had low grade intermittent fever which was relieved by taking tablet dolo.There is no history of burning micturition and low urine output.He had lower back pain.

HISTORY OF PAST ILLNESS:

There is a history of central line infection 3 months back.The patient is a known case of hypertension since 7 years.3 months back he underwent hemodialysis two times .

There is no  history of DM, asthma, TB, bronchial asthma and epilepsy.

PERSONAL HISTORY:

Marital status :married

Appetite: decreased since 3 months

Diet : mixed

Bowel and bladder habits: regular 

Sleep: adequate 

Addictions : was alcoholic since 30 years and stopped from 10 years.

FAMILY HISTORY:

There is no significant family history.

GENERAL EXAMINATION:

Conscious, coherent, co-operative

Moderately built,nourished.

 

PALLOR: ABSENT

ICTERUS:ABSENT

CYANOSIS: ABSENT

CLUBBING OF FINGERS/TOES: ABSENT

LYMPHADENOPATHY: ABSENT

PEDAL EDEMA: ABSENT

VITALS:

BP: 140/90 mmHg

Pulse rate : 82 bpm

Temperature:98.2 F

Respiratory rate: 16 cpm

 SYSTEMIC EXAMINATION :

CVS:

S1,S2 Sounds heard,

No audible murmurs,

Thrills:No.

RESPIRATORY SYSTEM:

Dyspnea is absent

Position of trachea:central,

Normal vesicular breath sounds are heard,

No adventitious sounds .

Per abdomen: soft and non tender.

Provisional diagnosis:

Chronic kidney disease with maintainence of dialysis .

INVESTIGATIONS: