CKD ON MHD GENERAL MEDICINE CASE 30-06-22

 GENERAL MEDICINE CASE (30-06-22)


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 - 22/06/22

CHIEF COMPLAINTS

-Patient aged 70yrs came to OPD with chief complaints of cough since 5days prior,burning sensation of feet and pedal edema.

HISTORYOF PRESENT ILLNESS

-C/O cough which is productive ,scanty,whitish in colour.

-Associated with chest pain.

-Pitting type of pedal edema upto ankle.

-Burning sensation of feet and decreased urine output.

HISTORY OF PAST ILLNESS

-K/C/O DM and HTN since 7years.

TREATMENT HISTORY

k/c/o DM,HTN

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

K/C/O blood transfusion (prbc-packed red blood cells)

H/O hysterectomy.

PERSONAL HISTORY

Mixed diet

Appetite Lost

Sleep adequate

Bowel movements regular.

Micturition abnormal.

FAMILY HISTORY

Not significant 

PHYSICAL EXAMINATION

Temp- 

BP-140/80 mm hg

Pulse rate-82/min

Respiratory rate-16/min

Spo2-

GRBS-236mg%

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

-edema present

SYSTEMIC EXAMINATION 


CARDIOVASCULAR SYSTEM

•S1, S2 heard

•Systolic murmur at tricuspid area

RESPIRATORY SYSTEM:

•NVBS heard

•Position of trachea - central

•Breath sounds - vesicular

-Decreased air entry on right side.

-B/L crepts at ISA and IAA.

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






















DIAGNOSIS:

CKD ON MHD






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