GENERAL MEDICINE CASE STUDY

CHIKATLA LAHARISHA ,ROLL NO 28
A 70 yr old female was brought by his son to the opd with the complaints of shortness of breath and bilateral pedal edema

chief complaints:

shortness of breath since one week

bilateral pedal edema  since five days

decreased urine output


HISTORY OF PRESENTING ILLNESS:

patient was apparently normal 5-6 years back.then she developed low grade fever on and off with generalised weakness and went to healthcare and diagnosed with diabetes.

one month back she had loose stools in small quantity3-4 episodes per day for 1-2 days .

since one week she deveolped shortness of breath initially on exertion but now at rest.bilateral pedema initially on ankle then generalised;facial puffiness and decreased urine output


HISTORY OF PAST ILLNESS

history of diabetes:5-6 yrs

no history of hypertension,tb,epilepsy


FAMILY HISTORY:

Not a k/c/o asthma,tb.epilepsy.htn


PERSONAL HISTORY:

married

occupation:daily wage labourer

diet:mixed

appetite:low

bowel and bladder movements are abnormal

no allergies

used medications for diabetes

GENERAL EXAMINATION

Physical examination:

moderately built

presence of pallor

no icterus

no cyanosis 

no lymphadenopathy

bilateral pedal edema

VITALS:

pulse rate:84/min

respiratory rate:22/min

BP:130/70


SYSTEMIC EXAMINATION:

CVS

s1 and s2 heard

no murmurs

no thrills

RESPIRATORY SYSTEM:

Dyspnoea

no wheezing

position of trachea is central

breath sounds are vesicular

ABDOMEN

No tenderness and no palpable mass

No bruits

liver and spleen are not palpable

bowel sounds are present

CENTRAL NERVOUS SYSTEM;

Conscious and coherent

speech is normal

no neckstiffness

sensory and motor system are intact

PROVISIONAL DIAGNOSIS:

             AKI ON CKD

INVESTIGATIONS:



hemogram on 11-6-2022








Hemogram on 12-06-2022. 





TREATMENT:

13/06/2022

IV FLUIDS

INJ LASIX 40MG/IV/TWICE A DAY

INJ PAN 40MG/IV/ONCE A DAY

INJ ZOFER 4MG/IV

TAB NODOSIS 500MG/TWICE A DAY

TAB OROFER-XD/ONCE A DAY

TAB SHELCAL 500MG/ONCE A DAY

TAB MVT/ONCE A DAY

INJ HAI THREE TIMES A DAY according to grbs

14/06/2022

IV FLUIDS

INJ LASIX 40MG/IV/TWICE A DAY

INJ PAN40 MG/IV/ ONCE A DAY

INJ ZOFER4 MG/IV

TAB NODOSIS 500 MG/TWICE A DAY

TAB OROFER-XD ONCE A DAY

TAB SHELCAL 500MG ONCE A DAY

TAB MVT/ONCE A DAY

INJ AUGMENTINE 625MG/TWICE A DAY

INJ HAI according to grbs

15/06/2022:

IV FLUIDS

INJ LASIX 40MG/IV/ TWICE A DAY

INJ PAN 40MG/IV/ONCE A DAY

INJ ZOFER 4MG/IV

TAB NODOSIS 500MG/TWICE A DAY

TAB OROFER-XD ONCE A DAY 

TAB SHELCAL 500MG/ONCE A DAY 

TAB MVT ONCE A DAY

INJ AUGMENTIN -625MG TWICE A DAY

INJ HAI according to grbs

16/06/2022 :

FLUID AND SALT RESTRICTION

INJ LASIX 40MG/IV/TWICE A DAY

INJ PAN 40MG/IV/ONCE A DAY

INJ AUGMENTIN -625MG TWICE A DAY IV

TAB NODOSIS 500MG ONCE A DAY

TAB OROFER-XD ONCE A DAY 

TAB SHELCAL 500MG ONCE A DAY

TAB MVT ONCE A DAY

INJ HAI ACCORDING TO GRBS THRICE A DAY

TAB NICARDIA 20MG/TWICE A DAY



















Comments

Post a Comment

Popular posts from this blog

General medicine E-log

Image
  58 yr old with stroke November 28, 2023 58 year old male construction worker by occupational came with chief complaints of Burning sensation at right upper half of the body since 2years History of present illness Patient was apparently asymptomatic 2years than one night he suddenly  complained  of loss of vision in both eyes and he developed weakness of right upper limb and lower limb and deviation of mouth to left side which is sudden in onset preceeded by 30-40 episodes of vomiting non-bilious , non-blood tinged, projectile which was associated with involuntary movements of both upper limbs and lower limbs , associated with frothing , tongue bite , outward fixation of left eye ball. After which patient went into coma for 3 months . He was taken to rk hospital Hyderabad treated there for 15 days than was brought back home . He was later taken to Khammam for treatment 3 times in a gap interval of 10 days still patient dint recover . Later they used some herbal medication and he regai
Read more

GENERAL MEDICINE CASE STUDY

Image
A 75 yr old male patient who is resident of nalgonda labourer by occupation came to our hospital for eye surgery  CHIEF COMPLAINTS: Loss of vision-left eye Itching all over th body HISTORY OF PRESENTING ILLNESS:  Patient has loss of vision in his left eye since one yr..he has itching all over the body since two months. HISTORY OF PAST ILLNESS: Patient was apparently asymptomatic 10 years back.Later,he developed deformities in his lower limbs(resorption and clawing of all the toes).he also lost all his senses(pain ,touch, temperature, vibration).he had hyperflexion of DIPJ nd hyperextension of PIPJ since 2-3 months .There is burning sensation allover his body. FAMILY HISTORY:     No history of DM HTN EPILEPSY asthma cardiovascular disease in his family PERSONAL HISTORY:  Mixed diet Married Normal bowel and bladder movements Abnormal sleep patterns No addictions GENERAL EXAMINATION: PHYSICAL EXAMINATION: No pallor  No icterus No cyanosis No lymphadenopathy No pedal edema Wasting of muscl
Read more