General medicine case 12-09-23

  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 and diagnosed with lupus nephritis and was on conservative management.

Pt was initially on hemodialysis since feb 2023

HISTORY OF PAST ILLNESS

He is a k/c/o HTN sicne feb 2023

Not a k/c/o DM,CVA,CVD,TB,Epilepsy,Asthma.

TREATMENT HISTORY

k/c/o HTN and on medication since feb 2023

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

Not a K/C/O blood transfusion (prbc-packed red blood cells).

PERSONAL HISTORY

Mixed diet

Appetite Lost

Sleep adequate

Bowel movements regular.

Micturition normal.

No addictions

FAMILY HISTORY

Not significant 

PHYSICAL EXAMINATION

Temp- 98.4 f

BP-150/80 mm hg

Pulse rate-74/min

Respiratory rate-19/min

Spo2-96

GRBS- 102mg.

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

-bilateral pedal edema present

SYSTEMIC EXAMINATION 


CARDIOVASCULAR SYSTEM

•S1, S2 heard

RESPIRATORY SYSTEM:

•NVBS heard

•Position of trachea - central

•Breath sounds - vesicular

ABDOMEN

•Shape - schaphoid

•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
























PROVISONAL DIAGNOSIS

CKD on MHD with k/c/o Hypertension 

TRETMENT

1.Fluid restriction <5L per day

2.Salt restriction <2gms per day

3.T.Nicardia 30mg po/bd

4. Tab predinisolone 5mg po/bd

5. Tab arkamime 0.1mg po/tid

6.Tab Shelcal-ct po/od

7.T NODOSIS 500mg po/bd

8. Monitor vitals 4th hourly

9. Inform SOS


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