General medicine E - LOG Book
Final practical examination : long case
R .Lalu prashanth
Hall ticket no : 1701006144
This is an online E-log book to discuss our patient de-identified healthdata shared after taking his/ her guardians sign informed consent
Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aimto solve those patient clinical problem with collective current bestevidence based inputs.
This E-log also reflects my patient centered online learning portfolio. I have been given this case to solve in an attempt to understand thetopic of " Patient clinical data analysis" to develop my competancy inreading and comprehending clinical data including history, clinicalfinding, investigations and come up with a diagnosis and treatmentplan
Case presentation :
A 65yr old male patient who is a resident of nakrekal and farmer
by occupation came to the OPD with the chief complaints of
Urinary retention since 2 days
Abdominal distention since 2 days
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 4 months back,then he
developed swelling of legs for which he went to a hospital in nakrekal
where he was diagnosed with renal calculi.he was treated
conservatively for that.
Then 1month back he went to same hospital for similar complaints as
pedal edema is not reducing for which he was referred to our
hospital.In our hospital he was diagnosed with CKD and he had
dialysis for 8 times.
Then 2 days back patient complained of abdominal distention which is
associated with mild pain
He also had urinary retention since 2 days
It is associated with dribbling of urine,burning micturition,brownish colour urine.
PAST HISTORY
He had right sided indirect inguinal hernia for which hernioraphy was
done 13 years back.
He is known case hypertension since 4 years and he is on medication
since 4 years
No history of diabetes,asthma,tb,cad,stroke
PERSONAL HISTORY
married
Diet:mixed
Appetite:normal
Sleep:adequate
Bowel and bladder:urinary retention
Addictions:regular alcoholic
FAMILY HISTORY:
family member has hypertension
No history of diabetes,asthma,tb,cad,stroke.
GENERAL EXAMINATION
Patient is concious,coherent,cooperative,moderately built and
moderately nourished
VITALS:
Temperature:98.7°F
Pulse rate:82b/m
Respiratory rate:22c/m
BP:140/70mmhg
Spo2:99
Grbs:134mg%
Pallor: present
Icterus:no
Clubbing:no
Cyanosis:no
Lymphadenopathy:no
Edema:present
SYSTEMIC EXAMINATION:
INSPECTION :
Shape:scaphoid
Umbilicus:central,inverted
Skin:normal
Dilated veins:no
No visible gastric peristalsis
Movements of abdominal wall:normal
PALPATION:
SUPERFICIAL PALPATION:
No Tenderness
No local rise of temperature
DEEP PALPATION:
liver:not palpable
Spleen:not palpable
Kidney:not palpable
PERCUSSION:
Fluid thrill:absent
Liver span:14cm
AUSCULTATION:
Bowel sounds:normal
EXAMINATION OF OTHER SYSTEMS:
CVS : S1,S2 Heard
no added heart sounds
RESPIRATORY SYSTEM:
broncho vesicular breath sounds heard
CNS EXAMINATION:
Motor system and sensory system intact
Investigations :
Provisonal diagnosis : Chronic kidney disease associated with renal calculi and ascites.
TREATMENT: 10/6/22 ,. 11/6/22
TAB LASIX - 400 Mg bd
Tab nodosis-500mg bd
Inj metrogel-500mg tid
Tab pan- 40mg od
Oroferxt- od
Tab shelcal-od
Tab nicardipine-20mg bd
Syp arystozyme-15ml bd
