General medicine case Acute kidney injury 28-06-22

 GENERAL MEDICINE CASE (28-06-22)


Welcome and greetings to every one who are visiting my blog. This is A.Sai Tarun of 5th 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 - 23/06/22

CHIEF COMPLAINTS

-45yr old female came to OPD with chief complaints of vomitings ,nausea and epigastric burning sensation.

HISTORYOF PRESENT ILLNESS

-Pt was apparently normal 4yrs back then she developed burning micturition, pedal edema, right loin pain for which she visited  local hospital.

-she diagnosed with rght renal caliculus with pyelonephritis  then referred to nims and there she went rght nephrectomy.

-since 10 -15 days she has been suffering with nausea,vomitings and epigastric discomfort.

- 4 to 5 episodes of vomitings with small quantity of food particles as it’s contents.

-No blood in vomitings.

HISTORY OF PAST ILLNESS

-Right nephrectomy in 2018

TREATMENT HISTORY

Not a k/c/o DM,HTN

Not a k/c/o CAD,TB,asthma,chemo,radiation and blood transfusion.

PERSONAL HISTORY

Mixed diet

Appetite Lost

Sleep adequate

Bowel movements regular.

Micturition abnormal.

FAMILY HISTORY

Not significant 

PHYSICAL EXAMINATION

Temp- afebrile

BP-130/80 mm hg

Pulse rate-82/min

Respiratory rate-16/min

Spo2-98%

-No signs of pallor,cyanosis,lymphadenopathy,icterus.

-Oedema present

SYSTEMIC EXAMINATION 


CARDIOVASCULAR SYSTEM

•S1, S2 heard

•No murmurs

RESPIRATORY SYSTEM:

•NVBS heard

•Position of trachea - central

•Breath sounds - vesicular

ABDOMEN

•Shape - scaphoid

•No Tenderness

•No palpable mass

 -No fluid present.

-No palpable liver or spleen


CENTRAL NERVOUS SYSTEM:

•Intact

•No focal defect

•No abnormality detected

CEREBRAL SIGNS

• No finger nose incordination

•No knee heel incordination.


INVESTIGATIONS















PROVISIONAL DIAGNOSIS 

Acute kidney injury 






Comments

Post a Comment

Popular posts from this blog

General medicine case 12-09-23

Image
   GENERAL MEDICINE CASE (12-09-23) Welcome and greetings to every one who are visiting my blog. This is A.Sai Tarun 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 - 17/08/23 CHIEF COMPLAINTS A 29yr old female patient came to general medicine opd with cheif complaints of SOB since 3days. HISTORY OF PRESENTING ILLNESS Patient was apparently aymptomatic till november 2022 . Then she had loss of hair and patches are developed. Bilatera Pedal edema is present which is of pitting type. Then she developed shortness of breath  which is  insidious in onset and gradually progressive in nature.  Renal biopsy was done
Read more

GENERAL MEDICINE ASSIGNMENT (JULY 2021)

  Name - A. Sri Sai Tarun Roll no - 03 BELOW IS THE LINK TO THE QUESTIONS ASKED TO US : http://medicinedepartment.blogspot.com/2021/07/medicine-paper-for-july-2021-bimonthly.html?m=1 QUESTION 1 -Below is the link of the student assignment for which I am sharing my peer review . https://shruthiarukonda02.blogspot.com/2021/07/shruthi-arukonda-02.html?m=1 Reviews to all the Questions answered :- 1) The reviews for the cases selected are well described. A detailed pinpoint review has been given to each particular case selected, which is helpful in easy analysis. Even though the peer reviews giving are short they are well described. There is even more possibility for more case depicting points which can be selectively described. 2) Every investigation and detailed history has been correctly described in order. The case of TMJ is depicted in the form of log which has each and every detail of the case. 3&4) The peer review is written on acute kidney injury on chronic kidney disease. A g
Read more

Meningitis and CAD 03 A SAI TARUN

Image
    GENERAL MEDICNE CASE  12-07-2021 Welcome and greetings to every one who are visiting my blog. This is A Sai Tarun of 3rd sem.  Introduction A 45 year old male is chronic alcoholic since 20 years carpenter by occupation was brought to causality in a state of altered sensorium since 1 day. CHIEF COMPLAINTS •Difficulty in walking & decreased appetite since 15 days. •Constipation since 5 days. •Fever and pedal edema since 3 days •Vomiting since 2 days. HISTORY OF PRESENT ILLNESS •Patient was apparently asymptomatic 6 months. Back until he had b/l pedal edema.he has diagnosed with hypothyroidism. •Patient had difficulty in walking and decreased appetite since then. •H/o constipation since 5 days. •Fever - low grade , intermittent , releived with treatment since 3 days. •B/l pedal edema - pitting , extending upto knees since 3 days. •Vomiting - non bilious , non projectile , associated with food particles since 2 days. •Altered sensorium since 1 day. •Not a k/c/o DM/HTN/Asthma/Epilep
Read more