General medicine elog 3

Anahita behara 

roll no 08

This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission.


I have 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 come up with a diagnosis and treatment plan 

A 50 year old female , resident of tirumalgiri came to the OPD with chief complaints of loss of appetite, vomiting , weakness since the past 2 days (29th july to 31st july 2021) and constipation since the last 10 days (22nd july 2021) , also complains of shortness of breath

-A known case of hypertension since 1 year 

-not a known case of diabetes mellitus, thyroid and tuberculosis  

Treatment history 

Was prescribed tablets for hypertension since one year but stopped taking the medicine 10 months ago as she was having body pains and thought that the tablets were the root cause 


Patient previously went to NIMS (GVK lane ) one year go for headache and shortness of breath after kidney scanning and blood tests she was diagnosed with a kidney disease and was prescribed tablets , however she stopped taking tablets 10 months ago as she thought the tablets caused her body pains 


She also opted for homeopathic treatment one year ago for the afore mentioned problems but discontinued the course 10 months ago 



Surgical history

Tubectomy (20 years ago )

personal history 

diet : mixed 

appetite : loss of appetite 

sleep: normal 

bowel movement : previously regular ; now hasn't passed stool since 10 days 

bladder : normal

no addictions 

no known allergies


general examination

pallour : not seen

icterus : not seen

cyanosis : not seen

clubbing : not seen

lymphadenopathy : not seen

pedal edema : not seen

Vitals 

temperature : afebrile 

pulse rate : 105 bpm

respiratory rate : 20 cpm 

blood pressure : 140/70 mmhg 

SPO2 at room air : 99%

GRBS ( General Random Blood Sugar ): 136 mg%

-----------------------------------------------------------------------------------------------------------------------------

Systemic examination

CARDIOVASCULAR SYSTEM 

-Thrills : absent 

-Cardiac sounds : S1 S2 heard

-Cardiac murmurs : absent 

RESPIRATORY SYSTEM 

-dyspnoea : is seen 

-wheeze : not heard 

-position of trachea : central 

-breath sounds : vesicular 

-adventitious sounds : B/L diffuse coarse +

ABDOMEN 

-shape of abdomen : obese

-tenderness : left hypochondria and iliac region 

-palpable mass : no 

-hernial orifices : normal 

-bruits : no 

-liver : not palpable 

-spleen : not palpable 

-bowel sounds : yes 

- genitals : normal 

CENTRAL NERVOUS SYSTEM 

—Level of consciousness: conscious and alert 

-speech: normal 

-no signs of meninges irritation

-cranial nerves , motor system and sensory system : normal 

Glasgow scale : 15/15

——————————————————————————————————————————-

Blood reports 

<hemogram >



<HBsAG-RAPID >





<BLEEDING AND CLOTTING TIME >



<PROTHROMBIN TIME>



<APTT>



<SERUM IRON>



Complete urine examination 

 


 Diagnostic imaging 

Ultra sound report 



ECG 



PROVISIONAL DIAGNOSIS

CRF (?)

3X3 cyst noted at inter polar region of kidney (found in ultrasound )

TREATMENT PLAN

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