general medicine practicals


THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT.    


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.


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 diagnosis and treatment plan


Chief complaints : b/l pain in lower limbs upto knees since 20 days 

B/l swelling in the leg since 20 days 

HOPi : Pt was appently asymptomatic 3 yrs back then he developed sudden pain in right side of abdomen for which he was diagnosed with renal calculi and got treatment and then icidently his creatinine level was 6.2mg/dl 

He also developed pain in lower limbs which is insidious in onset and gradually progressive , for which he went to hospital and is on medication since then 

20 days back he developed b/l pain in lower limbs which continuos and gradually progressive , pricking type in nature , aggravating on lifting weights and not relived on taking medication 

No h/o shortness of breath , pedal edema , decreased urine out put , facial puffiness

orthopnea, pnd , chest pain and palpitation 

HOPI 

N/k/c/o DM , HTN , cva, CAD , TB asthama 

K/c/o ckd since 3 years 

PERSONAL HISTORY 

diet - mixed 

Appetite - normal 

Bowel and bladder - regular 

No knoen allergies 

Occasional alcohol consumption 

Chronic smoker since 6 years ( stopped 8 months back) 

TREATMENT HISTORY 

H/o usage of NSAIDs for pain since 2 yrs 

FAMILY HISTORY 

Not significant 

General examination 

Patient was conscious coherent and cooperative 

No pallor icterus cyanosis clubbing lymadenopathy 

Pedal edema present - pitting type

Vitals 

BP -140/80

RR - 14/min

Temp - 98F 

Pulse rate - 78bpm 

Spo2 98percent 

Grbs - 134 mg%

SYSTEMIC EXAMINATION 

CVS - s1s2 heard no murmurs 

CNS - NFND 

PA - soft nontender 

RR - normal vesicular breath sounds 

INVESTIGATION 

HIV - non reactive 

HBsAg - negative 

RBS - 114 mg/dl

Blood urea - 176 mg/dl 

Serum creatinine - 7.8mg/dl 

PROVISIONAL DIAGNOSIS 

CHRONIC KIDNEY DISEASE secondary to NSAID abuse 

TREATMENT 

1) salt restriction <2 g /day 

 2) fluid restriction <1.5L /day 

 3) T.NODOSIS 500mg PO/BD 

4) T.OROFER-XT PO/OD

5) T.SHELCAL - CT PO/OD 

6) T.CAP BIO D3 60,000IU units per weekly 

 7) T.LASIX 10 mg PO/BD 

moniter vitals 4 th hrly 


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