General medicine case blog

  E-LOG GENERAL MEDICINE

Hi, This is vaishanavi, a fifth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve the problem.

A 59 year old male farmer who is a resident of nalgonda district admitted in the hospital with chief complaints of pain in bilateral lower limbs and oedema since 6 months

Pain is of dragging type associated with fever, relieved on medication.

Oedema is of pitting type grade 2.

Neck pain radiating to the hand since 1month.

HOPI:

Patient was apparently asymptomatic 20 years back then he developed pain and generalized weakness of the body which he stopped working as a farmer and started to stay near his farm.

3 years back patient developed pain in multiple joints increased with movements so went for local practitioner and was taking occasional NSAIDs once every 2 months.

6 months back patient started to develop swelling of both lower limbs from the level of thighs associated with pain in the lower limbs, oliguria since 1 month then came to our hospital. Pedal oedema subsided and is grade 2 pitting type not associated with chest pain.

Past history:

Patient is not a known case of diabetes mellitus, hypertension, asthma, CAD, TB, epilepsy.

Personal history:

Appetite: normal

Diet: mixed

Stopped non-veg 6 months back.

Bowel movements: regular

Addictions: occasionally alcohol.

Family history:

Not significant.

General examination:

Patient is conscious and coherent 

Moderately nourished

Well oriented to time and place

Pallor: present

Edema of feet: present

No icterus 

No cyanosis

No clubbing

No lymphadenopathy 

No malnutrition

No dehydration

Vitals:

Temperature: afebrile

Pulse rate: 12 bpm

Respiratory rate: 16 per minute

BP: 140/80

Systemic examination:

Thrills: no

Cardiac sounds: S1, S2 positive

Cardiac murmurs: no

Respiratory system: 

BAE +

Dyspnoea: no

Wheeze: no

Position of trachea: central

Breath sounds: vesicular

Abdomen: 

Shape: scaphoid

No tenderness

No palpable mass

No fluid

CNS: 

Level of consciousness- conscious 

Speech: normal

Cranial nerves: normal

No signs of meningeal irritation 

No motor or sensory deficit

Reflexes:

Biceps triceps supinato e knee ankle

Right +++++

Left +++++

Investigations

Treatment:

1.  Tab. LArIX

40mg /Po/BD

2. Tab NODOsIS 500mg /PO/ED

3.  Tab JHELCAL-D/PO/OD

4. Tab •OROFER-XT/PO/BD

5. Tab - PAN 40ng /PO| 0D |LAS

6. Tab METxL25mg /Po/0P

7. Tab- ECOSPRINAv (75/10) /PO/ OD

8. Tab- OUTRACET Y:TAb/ QID

9 . Inj ERYTHROPOLETIN 4000IV /s/e

twice weekly

10- VITALS MONITORING 8th MOORLY.

Provisional Diagnosis:

Chronic kidney disease.