Gm case...

Case scenario...
Hi ,I am M.Sindhupriya 3rd bds student.This is an online elog book to discuss our patient health data after taking his consent. This also reflects my patient centered online learning portfolio 

                  CASE HISTORY
Case sheet::A 76 years old male resident of nakrekal
Chief complaint:
Pedal edema : 1 month
Burning Micturition: 1 week
Shortness of breathe: 5 days
Decreased urine output: 3 days
History of present illness:
-Patient was apparently asymptomatic 1 month back then he developed pedal oedema which is pitting type intially upto ankle later progressed upto knee..
-Shortness of breathe since 5 days, insidious onset, gradually progressive from grade 1 to grade 2.
-Burning Micturition since 1 week
- Generalised swelling of body is seen since 3 days,B/l upper limb edema and abdominal distension since 3 days..
- No orthopnea,PND,No fever,cough, vomiting,loose stools.
History of past illness:
Patient has H/O type 2 DM since 10 years..
No H/O HTN,Asthma,  Tb ,Epilepsy,CVA,CAD..
No past surgical history 
Personal history:
Diet: mixed
Appetite: normal
Sleep: adequate
Bowel / bladder movements - regular
Addictions: alcohol consumption since 40 years
No allergies
Family history: 
No significant family history
General examination:
Pallor: no
Icterus: no
Cyanosis: no
Clubbing of fingers: no
Lymphadenopathy: no
Oedema: yes
Malnutrition: no
Dehydration: no
Vitals:
Pulse rate: 78 bpm
Bp: 140/ 60 mmhg
Temperature: 96.8 F
RR: 22 cpm
Spo2: 94%
Grbs:191 mg/ dl
Systemic examination:
1.Respiratory system
- no dyspnea
- no wheezing
- breathe sounds heard: vesicular normal
2.Cardiovascular system
- Cardiac sounds: S1,S2 heard
3.Abdomen
- shape: distended
- no tenderness
- no palpable mass
- non palpable liver
- no palpable spleen
- no bruits
- bowel sounds: heard
4.Cns
Conscious
Speech: absent
Coherent higher motor function is intact..
Provisional Diagnosis:
Congestive heart failure 
Q/A :Is he suffering with any kidney related disease?.
Is it curable?
Why it is associated with burning,micturition?




Popular posts from this blog

Gm Case..

Image
Case scenario... Hi ,I am M.Sindhupriya 3rd bds student.This is an online elog book to discuss our patient health data after taking his consent. This also reflects my patient centered online learning portfolio                    CASE HISTORY Case sheet: A 55 year old male ,came from gowraram to general medicine opd Chief complaints: Difficulty in lifting left upper limb & loss of speech no h/o mouth angle deviation HISTORY OF PRESENT ILLNESS: Patient was apparently Asymptomatic , But 10 days back difficulty in lifting left upper limb & loss of speech,then treatment at nalgonda hospital gradually recovered.  Duration: 12 hours Onset: sudden Time of occurrence: work Flaccid type of paralysis  Weakness:upper limb  Proximal: present Distal: present Lower limb weakness: absent Weakness of Trunk : absent  Weakness of Neck : absent H/o Sensory loss : Touch sensation:present Pain sensation: present Timbling sensation: present H/o loss of consciousness: present Vomiting: present Diarr
Read more

Gm case..

Image
Case scenario... Hi ,I am M.Sindhupriya 3rd bds student.This is an online elog book to discuss our patient health data after taking his consent. This also reflects my patient centered online learning portfolio                    CASE HISTORY Patient details: A 21 years old male Resident of choutuppal ,occupation by a student presented with the Chief complaints: Pain near the chest region followed by severe pain near the abdominal region since 2 week. Multiple episodes[30-40 times] of vomiting and breathlessness Since 2 days . History of present illness: Patient was apparently asymptomatic 2 weeks back then had pain near the chest region and followed by pain near the epigastric and umbilicus region which is insidious in onset and gradually progressive.....pain type dull thrombing . And patient is having multiple episodes of vomiting, that is 30-40 times per day since 2 days before coming to hospital.... Vomiting characteristics : 1)Non-projectile type of vomiting, as the patient fe
Read more